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CLINICAL  LECTURES 


ALBUMINURIA 


CLINICAL  LECTURES 


ON 


ALBUMINURIA. 


THOMAS  GRAINGER  STEWART,  M.D.  Edin. 

Fellmu  of  the  Royal  College  of  Physicians  of  Edinburgh  ; 

M.D.  Honoris  Causa  Royal  University  of  Ireland; 

Hon.  Fellow  King  and  Queen 's  College  of  Physicians  in  Ireland; 

Physician  in  Ordinary  to  Her  Majesty  the  Queen,  for  Scotland ; 

Professor  of  the  Practice  of  Physic  and  of  Clinical 

Medicine  in  the  University  of  Edinburgh. 


NEW   YORK: 
WILLIAM  WOOD  AND  COMPANY. 

1888. 


EDINBURGH  : 

PRINTED    BY    LORIMER    AND   GILLIES, 

31    ST.    ANDREW   SQUARE. 


N"  O  T  E. 

The  Lectures  comprised  in  the  present  series  have  been 
delivered  at  various  times  during  the  past  two  years,  and 
several  have  been  published  in  journals. 

It  has  often  been  suggested  that  I  should  issue  a  third 
edition  of  my  book  upon  "  Bright's  Diseases  of  the  Kidneys/' 
the  second  edition  of  which  has  now  for  many  years  been  out 
of  print.  I  have  sought  to  embody  in  these  Lectures  the 
views  which  I  entertain  regarding  the  chief  clinical  questions 
discussed  in  that  volume. 

My  thanks  are  due  to  numerous  friends  for  help,  and 
especially  to  Drs.  Stevens  and  Gulland  for  aid  in  making  the 
observations.  Dr.  Gulland  has  also  revised  the  sheets  and 
prepared  the  Index. 

T.  GRAINGER  STEWART. 


19  Charlotte  Square, 

Edinburgh,  April,  188S. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/clinicallecturesOOstew 


CONTENTS, 


LECTURE  I. 

On  the  Forms  op  Albumen  met  with  in  the  Urine,  and  their 
Tests,  Qualitative  and  Quantitative. 

PAGE 

Introduction. 

The  Varieties  of  Albumen — Serum  Albumen  —Serum  Globulin 
— Peptone  —  Propeptone  or  Hemialbumose — Acid  Albu- 
men —  Alkali  Albumen  —  Hsemoglobin— Fibrin— Mucin — 
Lardacein — Composition  of  Albumen. 

Tests  for  Albumen — Heat — Cold  Nitric  Acid — Metaphosphoric 
Acid — Acidulated  Brine — Picric  Acid — Potassio-Mercuric 
Iodide — Potassium  Ferrocyanide — Dilution  with  Water — 
Magnesium  Sulphate  —  Fehling's  Solution  —  Randolph's 
Test. 

Comparative  Delicacy  of  Tests  for  Serum  Albumen — Heat — 
Cold  Nitric  Acid— Metaphosphoric  Acid — Picric  Acid — 
Potassio  Mercuric  Iodide — Ferrocyanide  of  Potassium. 

Quantitative  Analysis  of  Albumen — Separation,  Drying,  Weigh- 
ing— Esbach's  Method — Robert's  Method — Oliver's  Percent- 
age Method, 1—16 

LECTURE  II. 

On  the  Incidence  op  Albuminuria  among  the  Presumably 
Healthy. 

Introduction. 

Contrariety  of  Opinions — Questions  to  be  discussed — Is  Albumen 
a  Natural  Constituent  of  Urine  ? — Proportion  of  presumably 
Healthy  People  showing  Albumen — Method  of  Testing — 
General  Result — Distinction  between  Soldiers  and  Civil 
Population — Between  Children  and  Old  People — Condition 
in  New-born  Infants — Results  of  Insurance  Experience — 
Effects  of  Diet,  of  Muscular  Exercise,  of  Severe  Exertion, 
of  Playing  Wind  Instruments,  of  Cold  Bathing,  of  Mental 
Excitement — Incidence  of  Peptonuria — Conclusions,    .         .       17 — 31 


Vlll  CONTENTS. 

PAGE 

LECTURE  III. 

On  the  Incidence  op  Albuminuria  among  the  Sick. 

Introduction. 

Series  of  Cases  Examined— Method  Adopted— General  Results 
in  Different  Groups — Categories  of  Causes  Denned — Series 
of  Cases  taken  together— Series  of  Private  Cases — Series  of 
Indoor  Hospital  Cases — Outdoor  Hospital  Cases — Patients 
in  Royal  Hospital  for  Sick  Children — Fever  House  Patients 
— Alcoholic  Cases— General  Conclusions  as  to  Incidence  of 
Serum  Albumen — Peptonuria  in  the  Different  Series,  .         .       32 — 48 

LECTURE  IV. 

On  the  Theory  op  Albuminuria. 
Introduction. 
Albuminuria    may  be  ascribed   to   Changes    in    the    Blood — 

Hydrsemia — Inspissation — Excess    of    Salts — Deficiency   of 

Salts — Excess  of  Albumen — Altered  Albumen. 
Altered  states  of  the  Filtering  Apparatus. 
Abnormal  Vascular  Tension — Diminution  of  Tension — Increase 

of  Tension. 
Changes  in  Epithelial  Cells  and  Stroma  of  Kidney. 
Conclusion, 49 — 67 

LECTURE  V. 

On  Albuminuria  prom  Inflammation  op  the  Kidneys. 

Synonyms — Case  of  Acute  Inflammation  with  Uraemia — Varieties 
of  Features  with  same  Lesion— Very  Chronic  Case — Non- 
Infective  Chronic  Case — Case  with  Pericarditis — Explana- 
tion of  the  Albuminuria,        ....;..       68 — 75 

LECTURE  VI. 

Albuminuria  prom  Cirrhosis  op  the  Kidneys. 

Synonyms — General  Features — Case  of  fully  developed  Disease 
— Case  in  Early  Stage— Renal  Inadequacy — Explanations  of 
the  Albuminuria,  ........       76 — 83 

LECTURE  VII. 

Albuminuria  from  Cirrhosis  op  Kidney — (Contimied). 

Clinical  Importance  of  the  Complications — Gastric  Catarrh  — 
Constipation — Morbid  States  of  Blood— Disorders  of  Circula- 


CONTENTS.  IX 

PAGE 

tion — Cardiac  Hypertrophy—  Degenerative  Changes — Valvu- 
lar Disease — Pericarditis — Changes  in  Arterial  Tension  and 
in  Vessels — Disorders  of  Respiration — Dyspnoea  from  Pul- 
monary Causes  —  Uraemic  Dyspnoea  —  Integumentary 
System — Dropsy, 84 — 95 

LECTURE  VIII. 

Albuminuria  from  Cirrhosis  of  Kidney — (Continued). 

Headache — Its  Varieties — Dimness  of  Vision — Uraemic — Due  to 
Organic  Causes — Retinal  Haemorrhage — Albuminuric  Retin- 
itis— Uraemia — Acute — Illustrative  Case — Chronic — Differ- 
ent Forms  of  Symptoms — Illustrative  Case — Causation  of 
Uraemia — Paralysis  and  Aphasia — Illustrative  Cases — 
Remarks, 96—113 

LECTURE  IX. 

Albuminuria  from  Waxy  or  Amyloid  Degeneration  of  the  Kidney. 

Case  of  Waxy  Disease  in  Early  Stage — Grounds  for  the  Diag- 
nosis— Causal  Complications — Concomitant  Complications — 
Polyuria — Termination  of  Case — Autopsy — Modes  of  Termi- 
nation of  the  Disease — Stages  of  the  Process — Explanation 
of  the  Albuminuria, 114 — 122 

LECTURE  X. 
On  Albuminuria  from  Fever  and  Other  Causes. 

Febrile    Albuminuria — Statements    of    previous     Observers — 

Explanation  of  the  Albuminuria. 
Albuminuria  from  Diseases  of  Circulatory  System — Explanation. 
Albuminuria  associated  with  Diseases  of  the  Alimentary  System 

— Explanation. 
Albuminuria  associated  with  Diseases  of  the  Nervous  System — 

Explanation. 
Albuminuria  with  Glycosuria, 123 — 137 

LECTURE  XL 

Albuminuria — Paroxysmal — Dietetic — From  Exercise — 
Simple  Persistent. 

Four  Categories — Sketch  of  Progress  of  Knowledge  on  this  Sub- 
ject— Christison — Jaccoud — Moxon — Gull — MorleyRooke — 
Barney  Yeo — Clement   Dukes — Mahomed — Fiirbringer — 

b 


X  CONTENTS. 

PAGE 

Runeberg — Saundby — Leube — George  Johnson — Quain  — 
Stanley  Kendall — Pavy — Magnire. 

Paroxysmal  Albuminuria — Illustrative  Case — Relation  to  Par- 
oxysmal Haemoglobinuria — Explanation — Treatment. 

Dietetic  Albuminuria — Illustrative  Cases — Positive  and  Negative 
— Theoretical  Explanations — Treatment. 

Albuminuria  from  Muscular  Exertion — Illustrative  Cases — 
Summing  up  of  Features — Theoretical  Explanation — Treat- 
ment. 

Simple  Persistent  Albuminuria — Illustrative  Cases — Summing 
up  of  the  Features — Theoretical  Explanation — Treatment. 

Prognosis  in  the  Four  Varieties,  ......  138—168 

LECTURE  XII. 

Albuminuria — Accidental,  &c. 

Number  found  in  Groups  of  Patients— From  Catamenial  and 
other  Discharges — Discharges  from  the  Urethra — Haemor- 
rhages and  Discharges  from  Prostate — Seminal  Fluid — From 
Bladder — From  Ureters  and  Pelvis  of  Kidney — Cases  of 
Renal  Calculus — Haemorrhage  from  the  Kidney. 

Albuminuria  of  Pregnancy — Albuminuria  from  Hindered  Out- 
flow due  to  other  causes. 

Explanation  of  the  Albuminuria  in  the  Series  of  Healthy  Indi- 
viduals— Renal  Disease — Accidental — Taking  of  Food — Vio- 
lent or  Prolonged  Muscular  Exertion — Playing  upon  Wind 
Instruments — Cold  Bathing — Mental  Conditions,  .         .  169—176 

LECTURE  XIII. 

On  the  Differential  Diagnosis  and  the  Prognosis  in 
Albuminuria. 

Diagnosis  —  Is  the  Albuminuria  Constant,  Intermittent,  or 
Cyclic  ? — Quantity  of  Albumen  discharged — Variety  of 
Albumen  present — Quantity  of  Urine  passed  daily — Specific 
Gravity — Tube  Casts — Other  Urinary  Conditions,  Phospha- 
turia,  Oxaluria,  Urates- — General  Considerations — Aliment- 
ary System — Haemopoietic  System — Circulatory  System — 
Respiratory  System — Integumentary  System — Nervous  Sys- 
tem— Locomotory  System. 

Prognosis — Importance  of  the  Drain  of  Albumen— Data  for 
estimating  daily  loss,  and  its  proportion  to  amount  of 
Albumen  in  the  Blood — Prognosis  in  Inflammatory  Bright's 
Disease  —  Cirrhosis  of  the  Kidneys — Waxy  Kidney — In 
Febrile  Albuminuria — In  Albuminuria  from  Alimentary 
Diseases — From  Nervous  Derangements — From  Glycosuria 


CONTENTS.  XI 

PAGE 

—In  Paroxysmal,  Dietetic,  Exercise,  and  Simple  Persistent 
Albuminuria — In  Accidental  Albuminuria — In  Albumin- 
uria from  Blood  Diseases, 177 — 192 

LECTUEE  XIV. 

Ox  Diet  ix  Albuminuria. 

Introduction— Production  of  Albuminuria  by  Diet — Evidence 
of  Stokvis,  Lelimann,  Lauder  Brunton,  Maguire,  Claude 
Bernard,  and  Others — Experiments  with  Egg  Diet ;  Cheese ; 
Walnuts — Diet  in  Bright's  Disease — Views  of  Dickinson  and 
Bartels — Experiments — Various  Diets — Results  in  Bright's 
Disease  and  Mixed  Forms  of  Albuminuria— Alcohol,   .         .  193 — 210 

LECTURE  XV. 

Ox  the  Effect  of  Medicines  in  Albuminuria. 

Introductory- — Treatment  of  Nephritis — Renal  Cirrhosis — Waxy 
Degeneration — Combined  Forms — Febrile  Albuminuria — 
Albuminuria  from  Circulatory  Disease — With  Alimentary 
Derangement — With  Nervous  Disease — With  Glycosuria — 
Functional  Albuminuria — Accidental  Albuminuria,     .         .  211 — 224 


LECTUKES  ON  ALBUMINUBIA. 


LECTURE    I. 

ON  THE  FORMS  OF  ALBUMEN  MET  WITH  IN  THE 
URINE,  AND    THEIR    TESTS,    QUALITATIVE    AND 

QUANTITATIVE. 

Introduction. 

The  Varieties  of  Albumen. — Serum  Albumen. — Serum  Globulin. — 
Peptone.  —  Propeptone  or  Hemialbumose. — Acid  Albumen. — 
Alkali  Albumen. — Haemoglobin. — Fibrin. — Mucin. — Lardacein. 
— Composition  of  Albumen. 

Tests  for  Albumen. — Heat. — Cold  Nitric  Acid. — Metaphosphoric 
Acid. — Acidulated  Brine.  —  Picric  Acid. — Potassio-Mer  curie 
Iodide.  - — ■  Potassium  Ferrocyanide.  —  Dilution  with  Water.  ■ — 
Magnesium  Sulphate. — Fehling's  Solution. — Randolph's  Test. 

Comparative  Delicacy  of  Tests  for  Serum  Albumen. — Heat. — Cold 
Nitric  Acid. — Metaphosphoric  Acid. — Picric  Acid. — Potassio- 
Mer curie  Iodide. — Ferrocyanide  of  Potassium. 

Quantitative  Analysis  of  Albumen. — Separation,  Drying,  Weighing  — 
Esbactis  Method. — Roberts's  Method. — Oliver's  Percentage  Method. 

r\  ENTLEMEN, — In  commencing  a  series  of  lectures  on 
^  albuminuria  as  a  symptom,  it  is  necessary  first  to  go 
over  some  ground  familiar  to  many  of  you,  for  I  must 
indicate  the  various  albuminous  substances  met  with  in  the 
urine.  I  purpose  in  the  present  lecture  to  enumerate  these, 
and  briefly  describe  the  source  and  nature  of  each,  and  then 
discuss  the  value  of  the  different  tests  by  which  they  may  be 
discovered.      In  doing  so  I  shall  give  you  the  results  of  a 


2  ALBUMINURIA. 

careful  and  prolonged  inquiry  which,  along  with  Dr.  Stevens, 
I  have  made  as  to  the  comparative  delicacy  of  the  leading 
tests  for  serum  albumen,  and  as  to  the  value  of  the  different 
methods  of  quantitative  analysis  by  which  the  amount  of 
albumen  may  be  determined.  In  the  urine  we  may  meet 
with  the  following  proteids,  or  bodies  closely  related  to  them. 

I.  Serum  Albumen,  a  substance  which,  according  to  Ham- 
marsten,(1)  constitutes  4-516  per  cent,  of  the  blood  serum. 
It  is  almost  constantly  present  in  urine  which  contains  any 
variety  of  albumen.  Although  a  less  diffusible  body  than 
serum  globulin,  it  is  capable  of  passing  through  membrane. 

II.  Serum  Globulin  or  Paraglobulin,  the  globulin  of  the 
blood  serum,  of  which  it  constitutes  3-103  per  cent.(1)  It  is 
met  with  in  almost  all  albuminous  urines,  its  proportion  to 
the  serum  albumen  varying  in  different  instances. 

III.  Peptone,  a  product  of  gastric  and  pancreatic  digestion 
of  albuminous  substances,  also  occurring  in  the  process  of 
transformation  of  tissues  and  of  inflammatory  effusions.  It  is  a 
readily  diffusible  substance,  occasionally  met  with  in  the  urine 
in  association  with  and  probably  apart  from  serum  albumen. 

IV.  Propeptone,  A  Ibumoses,  or  Qlobuloses,  a  group  of  sub- 
stances intermediate  between  proteids  and  peptone,  consti- 
tuting stages  of  transformation  from  the  one  to  the  other. 
They  are  highly  diffusible,  and  many  varieties  may  be  met 
with  in  the  urine.  One  of  them  is  the  peculiar  form  of 
albumen  which  was  discovered  by  Dr.  Bence  Jones (2)  in  the 
urine  of  a  patient  suffering  from  osteomalacia. 

V.  Acid  Albumen  or  Syntonin,  one  of  the  derived 
proteids  obtained  by  the  action  of  acids  upon  albumen.  It 
is  easily  produced  artificially  by  the  addition  of  acid  to 
albuminous  urine,  but  may  occur  naturally  in  certain  cases. 

VI.  Alkali  Albumen,  another  derived  proteid,  produced  by 
the  action  of  alkalies  upon  albumen.  It  may  be  readily  arti- 
ficially prepared,  but  also  occurs  in  the  urine. 


THE   VARIETIES    OF    ALBUMEN.  3 

VII.  Haemoglobin,  the  combination  of  hsematin  and 
globulin  naturally  existing  in  the  red  corpuscles  of  the 
blood.  It  sometimes  appears  in  the  urine,  particularly  in 
cases  of  hematuria  and  hemoglobinuria ;  also  in  certain 
septic  conditions,  after  inhalation  of  arseniuretted  hydrogen, 
transfusion  of  blood,  and  under  other  conditions. 

VIII.  Fibrin,  a  proteid  substance  which  does  not  normally 
exist  as  such  in  the  blood.  It  is  met  with  in  the  urine  in 
hematuria,  in  some  cases  of  chyluria,  and  in  certain  varieties 
of  renal  casts. 

IX.  Mucin,  the  chief  constituent  of  mucus,  is  a  derived 
proteid  substance,  not  an  albumen  but  an  albuminoid.  As 
mucus  is  secreted  from  the  urinary  tract  in  greater  or  less 
quantity,  it  becomes  superadded  to  the  urine  after  its  secre- 
tion in  the  kidney. 

X.  Lardacein,  Waxy  or  Amyloid  Material,  familiarly 
known  as  a  pathological  substance  within  the  body,  is  said 
to  be  occasionally  demonstrable  in  renal  casts. 

Of  these  ten  varieties,  the  last  four  are  evidently  of  little 
practical  importance — mucin  alone  being  indeed  worthy  of 
special  comment,  and  that  mainly  because  of  the  difficulties 
which  its  presence  raises  in  regard  to  the  reliability  of  certain 
tests  for  serum  albumen. 

As  to  the  composition  of  the  various  albuminous  sub- 
stances, it  is  scarcely  necessary  that  I  should  say  anything, 
but  I  may  quote  the  statement  of  Hoppe-Seyler,(3)  that  their 
percentage  composition  varies  from 

C51-5  H6-9  N15-2  S0"3  0  20-9  to 
C  545  H  7-3  N  17'0  S  20  0  23-5 


The  Tests  for  the  Albumens. — I  have  put  in  tabular  form 
the  chief  tests  for  the  different  varieties  of  albumen,  with 
their  actions  upon  each  variety. 


ALBUMINURIA. 


Table  I. — Showing  Tests  for  the  Chief  Forms  of  Albumen. 


Serum 
Albumen. 

Serum 
Globulin. 

Peptones. 

Propeptones, 

Acid 
Albumen. 

Alkali 
Albumen. 

Heat,     . 

Opacity. 

Opacity. 

0 

0 

0 

0 

Heat      with 
HN03. 

Opacity. 

Opacity. 

0 

0 

0 

Opacity. 

Heat  with  A 

Opacity. 

Opacity. 

0 

0 

0 

Opacity. 

Cold  HN03,  . 

Opacity. 

Opacity. 

0 

Opacity 
dissolved 
by  heat. 

Opacity. 

Opacity. 

Metaphos- 
phoric  acid. 

Opacity. 

Opacity. 

Opacity 
diminished 
or  dissolv- 
ed by  heat. 

Opacity 
diminished 
or  dissolv- 
ed by  heat. 

0 

Opacity. 

Acidulated 
brine. 

Opacity. 

Opacity. 

Opacity 
diminished 
or  dissolv- 
ed by  heat. 

Opacity 
diminished 
or  dissolv- 
ed by  heat. 

Opacity. 

Opacity. 

Picric  acid,     . 

Opacity. 

Opacity. 

Opacity 
dissolved 
by  heat. 

Opacity 
dissolved 
by  heat. 

Opacity. 

Opacity. 

Potassio-mer- 
curic  iodide. 

Opacity. 

Opacity. 

Opacity 
dissolved 
by  heat. 

Opacity 
dissolved 
by  heat. 

Opacity. 

Opacity. 

Potassium 
Ferrocyanide 
with  A. 

Opacity. 

Opacity. 

0 

Opacity 
dissolved 
by  heat. 

Opacity. 

Opacity. 

Ammonium 
sulphate. 

Opacity. 

Opacity. 

0 

Opacity. 

Opacity. 

Opacity. 

Dilution  with 
water. 

C 

Slight 
opacity. 

0 

0 

0 

0 

Magnesium 
sulphate. 

0 

Opacity. 

0 

0 

Opacity. 

Opacity. 

Fehling's  solu- 
tion. 

Brown- 
ish-red 
or 
mauve. 

Rose  pink 
or  purple. 

Rose  pink 
or  purple. 

Randolph's  test, 

... 

Yellow           Yellow 
opacity.          opacity. 

The  oldest  test  for  albumen  depends  upon  its  coagulability 
by  heat.  Heat  coagulates  the  serum  albumen  (opalescence 
occurring  at  140°  Fah.,  coagulation  at  162°  to  167°),  and 
also  the  serum  globulin  (opalescence  occurring  at  154°  Fah., 
coagulation  at   167°);   has  no  effect  upon  the  peptones  or 


THE    TESTS   FOR   THE   ALBUMENS.  5 

propeptones,  nor  upon  acid  or  alkali  albumen,  unless  an 
alkali  or  acid  has  first  been  added.  It,  however,  produces 
cloudiness  with  earthy  phosphates,  by  driving  off  carbonic 
acid,  which  holds  them  in  solution,  but  the  further  addition 
of  nitric  acid,  by  redissolving  them,  clears  up  the  opacity. 
A  preliminary  acidulation  with  acetic  or  nitric  acid  prevents 
this  cloudiness,  but  may  convert  albumen  into  acid  albumen, 
and  so  make  the  test  fail.  But,  on  the  whole,  if  cautiously 
employed,  heat  gives  satisfactory  results.  A  further  security 
may  be  obtained  by  using  both  acetic  acid,  and  a  concen- 
trated solution  of  magnesium  sulphate,  or  of  sodic  sulphate, 
or  of  common  salt,  for  these  prevent  the  undue  action  of 
the  acid  upon  the  albumen. 

The  Gold  Nitric  Acid  Test  ranks  next  in  date  of  intro- 
duction and  in  general  popularity  to  that  by  heat.  When  a 
layer  of  nitric  acid  is  brought  into  contact  with  a  layer  of 
albuminous  urine,  a  white  coagulum  is  formed  at  the  line  of 
junction  of  the  fluids.  The  acid  coagulates  serum  albumen 
and  serum  globulin  ;  has  no  effect  upon  peptones  ;  gives  an 
opacity  with  propeptones,  which,  however,  disappears  with 
heat ;  has  no  effect  upon  acid  albumen,  but  gives  distinct 
reaction  with  alkali  albumen.  One  or  two  sources  of  fallacy 
must  be  kept  in  view  when  one  employs  this  test.  It  may 
give  an  opacity  with  urates  (but  it  dissolves  with  heat),  with 
urea  (but  it  occurs  only  in  concentrated  urines,  and  shows  a 
crystalline  arrangement),  or  with  resinous  substances. 

Metaphosphoric  Acid  is  an  excellent  test  for  albumen,  but 
as  it  is  only  serviceable  when  pure,  and  difficult  to  keep  in 
that  condition,  it  has  not  come  into  general  use. 

Acidulated  Brine  is  also  a  test  of  considerable  value, 
acting  upon  all  varieties  of  albumen,  but  it  is  not  likely  to 
become  greatly  trusted,  because  of  its  frequently  giving  some 
reaction  with  normal  urine. 

Picric  Acid  is  a  test  which  has  been  brought  into  use  in 


6  ALBUMINURIA. 

this  country  mainly  by  the  recommendation  of  Dr.  George 
Johnson.(4)  It  produces  an  opacity  with  all  the  forms  of 
albumen ;  but  while  those  with  serum  albumen,  serum 
globulin,  acid  and  alkali  albumen  persist  or  become  more 
distinct  with  heat,  those  with  peptone  and  propeptone 
dissolve.  It  must  be  remembered,  also,  that  alkaloids,  such 
as  quinine,  give  a  cloud  with  this  reagent,  but  one  which 
rapidly  disappears  on  heating.  On  the  whole,  I  believe 
this  to  be  the  most  reliable  and  delicate  test  which  we  at 
present  possess. 

It  has  been  objected  to  this  test,  that  it  precipitates  mucin 
as  well  as  serum  albumen,  and  that  this  is  a  source  of  fallacy, 
particularly  when  it  is  used  by  the  contact  method.  As  this 
question  appeared  to  me  important,  I  have  taken  a  good  deal 
of  pains  to  satisfy  myself  regarding  it.  By  the  kind  per- 
mission of  Dr.  Sinclair,  I  examined,  along  with  Dr.  Stevens 
and  Dr.  Boddie,  the  urine  of  a  number  of  inmates  of  Craig- 
lockhart  Poorhouse,  in  whom  previous  examination  had 
shown  that  minute  traces  of  albumen  were  frequently 
present,  and  in  which,  as  in  most  urines,  mucin  was  also  to 
be  found.  My  object  was  to  see  how  far  the  reactions  of  the 
characteristic  tests  for  mucin  corresponded  to,  and  how  far 
they  differed  from  those  of  picric  acid.  The  specimens, 
fifty-four  in  number,  derived  from  twenty-seven  individuals, 
were  tested  with  nitric  acid,  picric  acid,  a  solution  of  citric 
acid  of  specific  gravity  1005,  and  the  solution  of  citric  and 
picric  acids  together  used  in  Esbach's  method  for  determin- 
ing the  quantity  of  albumen.  The  contact  method  was 
adopted  in  all  cases  as  being  the  most  delicate.  The  nitric 
acid  was  used  in  order  to  show  when  albumen  was 
present  in  considerable  quantity  ;  the  picric  acid  to  discover 
minute  traces  of  albumen,  and  with  the  special  view  of 
watching  for  the  reaction  with  mucin  ;  the  citric  acid  as  the 
best  test  for  mucin  ;  and  the  combined  citric  and  picric  acids 


THE    TESTS PICRIC    ACID.  7 

for  the  purpose  of  comparison  with  the  reactions  obtained 
with  the  other  tests.  Of  the  fifty-four  specimens,  twelve 
showed  a  reaction  with  nitric  acid,  thirty-four  with  picric, 
thirty-eight  with  citric,  and  forty-one  with  Esbach's  combined 
solution.  The  most  important  fact  which  we  ascertained 
was  that,  while  a  large  number  of  the  specimens  gave  distinct 
reactions  both  with  picric  and  citric  acids,  there  were  three 
which  gave  an  opalescence  with  picric  and  not  with  citric,  and 
seven  of  those  which  reacted  with  citric  acid  gave  no  reaction 
with  picric.  From  these  facts  we  conclude  that  mucin  may 
be  demonstrated  by  citric  acid  when  no  reaction  is  produced 
with  picric,  and  that  picric  may  show  minute  quantities  of 
albumen  in  urines  in  which  citric  acid  fails  to  show  mucin. 

But,  on  the  other  hand,  picric  acid  often  produces  an 
opalescence  in  urine  apparently  free  from  albumen,  and  Dr. 
Stevens  made  a  series  of  careful  experiments  with  the  view  of 
getting  at  an  explanation  of  this  fact.  He  selected  a  urine 
which  gave  a  faint  and  slowly  developed  reaction  with  picric 
acid,  and  a  distinct  opacity  with  citric  acid.  Having  coagu- 
lated its  mucin  by  means  of  citric  acid  and  filtered  off  the 
coagulum,  he  found  that  the  urine  no  longer  gave  any 
reaction  with  picric  acid.  Again,  to  another  specimen  of  the 
same  urine  he  added  picric  acid  and  then  filtered  off  the  precip- 
itate ;  he  found  that  the  urine  then  gave  either  no  reaction,  or 
a  very  slight  one,  with  citric  acid.  These  experiments  seem 
to  indicate  that  picric  acid  does  act  upon  mucin,  although 
more  slowly  and  in  a  less  degree  than  citric  acid.  I  suspect 
that  the  degree  of  acidity  of  the  urine  is  an  important  element 
in  relation  to  this  reaction  with  picric  acid ;  that  where  acid 
is  present  in  quantity  the  opalescence  is  distinct,  where  it  is 
in  slight  amount  it  is  comparatively  or  completely  absent. 

On  the  whole,  we  seem  to  be  warranted  in  believing  that 
although  picric  acid  often  affects  mucin,  it  does  not  do  so 
in  such  a  way  as  to  render  it  unreliable  as  a  delicate  test  for 


ALBUMINURIA. 


albumen.  Its  precipitate  with  mucin  is,  even  when  applied 
by  the  contact  method,  a  slight,  slowly  developed  haze.  A 
precipitate  indicating  albumen  is  more  marked  and  more 
quickly  produced.  A  little  practice  in  the  use  of  the  test 
will  soon  render  you  familiar  with  the  degree  and  rate 
of  formation  of  the  opacity  which  indicate  albumen  as 
distinguished  from  those  which  mark  the  presence  of  mucin. 

Potassio-Mercuric  Iodide,  which  was  first  proposed  as  a 
test  by  M.  Tanret,(5)  corresponds  in  its  action  to  picric  acid, 
giving  opacity  with  serum  albumen,  globulin,  acid  and  alkali 
albumen,  and  an  opacity  dissolved  by  heat  with  peptone  and 
propeptone.  But  it  will  be  found  to  give  a  reaction  with  a 
very  large  proportion  of  normal  urines,  and  as  the  addition 
of  an  organic  acid — citric  or  acetic — is  required  to  bring  out 
the  reaction,  it  is  clear  that  mucin  must,  in  many  cases 
give  a  degree  of  opalescence.  It  may  be  that  other  sources 
of  fallacy  exist  in  regard  to  these  slighter  reactions.  It  is 
true  that  Dr.  Oliver's (6)  method  of  applying  this  test  greatly 
reduces  the  chances  of  error,  but  it  has  disadvantages  which 
render  it,  in  my  opinion,  inferior  to  picric  acid. 

Potassium  Ferrocyanide,  first  suggested  by  Dr.  Pavy,(7) 
also  resembles  picric  acid  in  its  action,  except  that  it  does  not 
give  any  indication  with  peptones.  The  objections  to  the 
reagent  last  described  apply  equally  to  this. 

Ammonium  Sulphate  has  been  shown  by  J.  Wenz(8)  to  be 
a  valuable  test  for  proteids,  for  it  precipitates  all  of  them, 
excepting  the  peptones,  and  Halliburton (9)  recommends  it 
highly  as  a  test  of  special  value. 

Dilution  with  Water  is  a  convenient  but  not  very  reliable 
test  of  the  presence  of  serum  globulin,  as  it  produces  a  milk- 
iness,  that  substance  being  soluble  in  weak  saline  solutions, 
but  not  in  pure  water  or  extremely  dilute  saline  solutions. 
It  produces  no  effect  upon  other  forms  of  albumen. 

Magnesium  Sulphate  is  a  valuable  test  for  serum  globulin, 


THE    TESTS FEHLING'S    SOLUTION,    ETC.  9 

as  it  produces  with  that  substance  a  milky  opacity,  which 
speedily  deposits  as  a  precipitate.  It  has  no  action  upon 
serum  albumen,  peptone  or  propeptone,  but  produces  an 
opacity  with  acid  and  alkali  albumen.  It  is  best  used  in 
saturated  solution  by  the  contact  method.  By  using  it  also, 
according  to  methods  described  in  works  dealing  with  the 
subject  of  physiological  chemistry,  the  globulin  may  be 
separated  nearly  pure,  and  its  amount  determined. 

Fehling's  Solution,  or  other  alkaline  solution  of  copper,  is 
a  most  convenient  test  for  peptone  and  propeptone,  giving 
with  these  a  rose  pink  or  purple  colour  at  the  point  of 
contact  of  the  solution  with  the  supernatant  urine,  and  pro- 
ducing no  effect  upon  the  others,  with  the  exception  of 
serum  albumen,  with  which  it  sometimes  gives  a  brownish- 
red  hue.  "With  all  albumoses  in  solution  a  pink  colour 
is  obtained  with  a  solution  containing  a  trace  of  copper 
sulphates  and  an  excess  of  potash.  This  is  known  as  the 
Biuret  reaction. 

Randolph's  Test (10)  for  peptone  and  propeptone,  which  con- 
sists in  the  addition  of  one  drop  of  saturated  solution  of  iodide 
of  potassium  and  then  of  two  drops  of  Millon's  reagent  (an  acid 
solution  of  nitrate  of  mercury)  to  a  drachm  of  urine,  gives  a 
yellow  instead  of  a  red  precipitate  when  these  substances  are 
present  ;  but,  as  Dr.  Oliver (11)  has  pointed  out,  it  gives  the 
same  colour  reaction  with  bile  salts,  which  are  frequently 
present  in  considerable  amount  in  the  urine.  Therefore  we 
cannot  esteem  it  so  highly  as  the  copper  and  alkali  test. 

Although  you  are  probably  familiar  with  the  general  out- 
line of  the  facts  I  have  thus  brought  before  you,  I  have 
thought  it  well  to  draw  them  up  in  a  tabular  form,  and  to 
make  these  comments  upon  them.  I  shall  only  add,  that 
the  presence  of  haemoglobin  may  be  detected  by  the  guaiac 
test ;  and  its  derivations,  such  as  methsemoglobin,  by  the 
spectroscope  :  that  the  presence  of  fibrin  may  be  ascertained 


10 


ALBUMINURIA. 


by  its  decomposing  hydrogen  peroxide  with  effervescence ;  that 
mucin  may  be  discovered  by  means  of  citric  or  acetic  acid ; 
and  that  waxy  material  may  be  shown  (if  it  is  ever  present)  by 
iodine,  iodine  and  sulphuric  acid,  or  by  methyl-aniline  violet- 


I  shall  now  show  you  the  results  of  the  investigation 
which  we  made  with  the  view  of  determining  the  com- 
parative delicacy  of  the  chief  tests  for  serum  albumen.  The 
method  which  we  adopted  was  to  take  an  albuminous  urine, 
determine  the  proportion  of  albumen  by  Esbach's  tubes, 
dilute  it  by  successive  additions  of  normal  urine,  and  note 
the  point  at  which  each  test  failed  to  give  its  characteristic 
reaction.  I  wish  you  to  observe  that  we  employed  normal  urine 
as  our  diluting  fluid,  as  we  found  that  the  substitution  of  water 
produced  a  misleading  result.  Indeed,  I  was  led  into  error  by 
this  circumstance  in  a  series  of  observations  which  I  made  a 
number  of  years  ago — cold  nitric  acid  giving  a  much  better 
result  with  water  than  it  would  have  done  with  healthy  urine. 


Table  II. 


-Showing  the  Comparative  Delicacy  of  Tests 
foe  Serum  Albumen. 


Tests. 

Dilutions. 

Percentage. 

Grains  per  Ounce. 

Boiling, 

300 

0-0005 

0-00218 

Acidulation  with 
acetic  acid,  and 
boiling. 

500 

0-0003 

0-001311 

Cold  nitric  acid,  . 

50 

0-003 

0-01311 

Metaphosphoric 
acid. 

500 

0-0003 

0-001311 

Picric  acid, . 

1000 

0-00015 

0-000655 

Potassio-mercuric 
iodide        (Test 

500 

0-0003 

0.001311 

papers). 

Ferrocyanide     of 
potassium. 

500 

0-0003 

0-001311 

COMPARATIVE    DELICACY    OF    TESTS.  11 

In  Table  II.  I  show  you  the  results.  In  parallel  columns 
I  have  represented  the  effects  of  each  of  the  tests  ;  showing 
in  the  first  the  dilution  up  to  which  the  action  of  each 
reagent  remained  distinct,  in  the  second  the  percentage  of 
albumen  as  calculated  from  the  total  quantity  in  the 
undiluted  fluid  and  the  number  of  dilutions,  and  in  the 
third  the  grains  or  part  of  a  grain  per  ounce  as  calculated 
from  the  same  data. 

The  urine  with  which  we  worked  contained  albumen  to 
the  amount  of  1*5  grammes  per  litre,  which  is  equal  to  0*15 
per  cent,  or  0*655  of  a  grain  per  ounce. 

Our  results  show  that  the  boiling  test,  carefully  applied, 
is  an  excellent  one,  revealing  the  presence  of  so  little  as 
0*00218  of  a  grain  per  ounce,  and  continuing  to  show  up  to 
the  300th  dilution  of  our  standard  specimen.  But  heat, 
with  preliminary  acidification  with  a  little  acetic  acid,  was 
still  more  delicate,  showing  0-001311  of  a  grain  per  ounce, 
and  giving  a  perceptible  haziness  up  to  500  dilutions. 

The  Gold  Nitric  Acid  Test  falls  far  short  of  this  in 
delicacy,  for  we  found  that  it  does  not  give  distinct  reaction 
beyond  the  50th  dilution,  and  therefore  shows  only  with 
0*01311  of  a  grain  per  ounce.  It  is  true  that  if  the 
specimen  is  allowed  to  stand,  the  reaction  may  gradually 
manifest  itself,  with  more  minute  traces  of  albumen  :  but 
this  is  inconvenient,  and  for  practical  use  tests  are  to  be 
valued  in  proportion  to  their  rapidity  of  action. 

Metaphosphoric  Acid  gave  the  same  results  as  heating 
after  acidulation  with  acetic  acid,  giving  opalescence  up  to 
the  500th  dilution  of  our  standard  urine,  and  showing 
0*001311  of  a  grain  per  ounce. 

Picric  Acid  proved  the  most  delicate  test,  giving  a  faint 
but  perceptible  reaction  up  to  the  1000th  dilution  of  our 
standard  specimen,  which  is  equal  to  0*00015  per  cent.,  or 
0*000655  of  a  grain  per  ounce. 


1 2  ALBUMINURIA. 

The  Potassio-  mercuric  Iodide  and  the  Ferrocyanide  of 
Potassium  Tests  gave  the  same  results  as  metaphosphoric 
acid,  showing  albumen  up  to  the  500th  dilution  of  our 
standard  specimen,  equal  to  0-001311  of  a  grain  per 
ounce. 

From  these  and  other  observations  I  am  led  to  conclude 
that  picric  acid  is  the  most  delicate  of  all  the  reagents  which 
we  possess  for  albumen,  and  that  next  to  it  rank  the 
potassio-mercuric  iodide,  the  heating  after  acidulation  with 
acetic  acid,  the  ferrocyanide  of  potassium,  and  the  metaphos- 
phoric acid.  Boiling  and  adding  nitric  acid  is  less  delicate, 
and  still  less  so  is  the  cold  nitric  acid  test. 

But  delicacy  is  not  the  only  quality  required  of  a  test. 
Indeed,  a  test  may  be  too  delicate  for  clinical  purposes. 
And  again  tests  otherwise  suitable  may  be  practically  incon- 
venient. Nitric  acid  is  difficult  to  carry  about,  and  picric 
acid  presents  a  similar  disadvantage,  although  in  a  minor 
degree.  The  test  pellets  devised  by  Dr.  Pavy (12)  of  London, 
and  the  test  papers  of  Dr.  Oliver (13)  of  Harrogate,  are 
extremely  convenient,  being  easily  carried  about,  and  very 
delicate.  But  it  may  be  held  that  they  are  too  delicate,  for 
few  urines  fail  to  show  some  reaction  with  them.  Indeed, 
you  will  find  that  many  of  them,  as  I  have  told  you  (and 
the  same  is  true  of  tungstate  of  soda),  show  some  reaction 
with  practically  normal  urines.  The  smallest  quantity  of 
mucin,  or  a  quite  infinitesimal  trace  of  albumen  proper, 
may  suffice  to  produce  the  reaction.  Therefore,  I  should 
advise  you  to  learn  to  use  the  tests  with  discrimination,  and 
not  to  attach  much  importance  to  their  fainter  indications, 
and  always  remember  that  albuminuria  is  rarely  a  serious 
condition  unless  it  is  sufficiently  pronounced  to  be  made 
out  by  the  cold  nitric  acid  test. 


METHODS    OF    QUANTITATIVE    ESTIMATION.  13 

The  last  point  to  which  I  shall  direct  your  attention  to- 
day is  the  results  we  have  obtained  by  a  series  of  experiments 
comparing  the  methods  most  used  for  determining  the 
quantity  of  albumen  in  any  given  sample  of  urine.  A  rough 
plan  often  adopted  is  to  boil,  then  add  a  little  nitric  acid, 
set  the  test  tube  aside  for  twenty-four  hours,  and  then  note 
the  proportion  of  the  coagulum  to  the  whole  height  of  the 
column.  This  may  be  useful  in  determining  the  progress  of 
a  case  day  by  day,  but  is  of  no  scientific  value.  We  have 
carefully  compared  the  results  obtained  in  this  way  with  the 
ingenious  plan  suggested  by  Dr.  Oliver  for  bringing  out  the 
result  without  waiting  twenty-four  hours.  This  is  known 
as  Dr.  Oliver's  fractional  method. (14)  He  uses  a  graduated 
tube,  a  paper  ruled  with  dark  lines,  and  his  mercuric  iodide 
or  potassium  ferrocyanide  test  papers.  The  graduation  on 
the  tube  is  so  marked  as  to  correspond  with  the  fractions 
of  a  column  in  an  ordinary  test  tube.  The  test  papers  are 
put  into  the  tube  along  with  6  0  minims  of  water,  and  urine 
added  until  it  is  no  longer  possible  (on  account  of  the 
increasing  opacity  of  the  fluid)  to  make  out  the  lines  behind ; 
the  mark  reached  by  the  urine  is  intended  to  correspond  to 
the  fraction  which  would  have  settled  at  the  end  of  twenty- 
four  hours.  Now  we  found  that  Dr.  Oliver  has  hit  this  very 
correctly,  for  when  our  coagula  stood  in  the  test  tubes  at 
one-fourth  to  one-third,  we  found  that  we  got  by  Dr.  Oliver's 
fractional  method  an  almost  identical  result.  But  this  is 
only  of  service  for  comparison  of  the  progress  of  a  case  dav 
by  day,  and  in  good  clinical  work  we  have  to  aim  at  some- 
thing more  definite. 

Various  plans  have  been  suggested  for  giving  more  accurate 
results.  Those  which  we  tested  were  coagulating,  drying, 
and  weighing,  and  the  methods  of  Esbach,  Roberts,  and 
Oliver,  applying  each  to  samples  of  the  same  urine. 

I.  The  Separation,  Drying,  and  Weighing  of  the  Albumen. 


1 4  ALBUMINURIA. 

— This,  which  is  the  fundamental  and  best  method  for 
ascertaining  the  amount  of  albumen,  is  somewhat  difficult, 
and  requires  considerable  time  for  its  performance.  It  is 
much  too  laborious  to  be  freely  used  as  a  clinical  method. 
One  has  to  acidulate  the  urine  slightly  with  acetic  acid,  then 
place  it  in  a  water  bath  at  a  temperature  of  100°  C,  stirring 
frequently,  so  as  to  prevent  the  formation  of  bulky  clots. 
The  coagulated  albumen  is  then  allowed  to  settle,  carefully 
separated  from  the  fluid,  and  placed  upon  a  filter  previously 
weighed.  It  is  then  put  into  a  hot  air  bath  and  slowly 
dried.  After  cooling  it  is  weighed,  then  again  put  into  the 
hot  air  bath,  and  the  process  is  repeated  until  the  filter 
ceases  to  lose  weight.  Thereby  the  amount  of  albumen 
is  accurately  determined.  In  the  urine  which  we  used  we 
found  3 "84 207  grains  in  the  cubic  centimetre,  equivalent  to 
1-0911  grains  per  ounce. 

II.  EsbacliS  Method.^ — This  plan  requires  certain  special 
tubes,  graduated  so  as  to  show  the  height  to  which  the  urine 
to  be  tested,  and  that  to  which  the  reagent  (a  solution  of 
picric  and  citric  acids)  should  reach,  also  the  number  or 
proportion  of  grammes  of  albumen  per  litre.  The  urine 
(diluted  with  water  until  the  specific  gravity  is  not  above 
1010,  and  acidulated  with  acetic  acid  if  necessary)  is  filled 
up  to  the  level  indicated  by  the  letter  U,  then  the  test  fluid 
to  the  line  marked  R,  and  the  fluids,  having  been  thoroughly 
mixed,  are  set  aside  to  stand  for  twenty-four  hours.  At  the 
end  of  that  time  the  level  reached  by  the  coagulum  enables 
us  to  read  off  the  grammes  per  litre.  Our  observations 
brought  out  a  result,  as  is  seen  in  the  table,  of  2*5  grammes 
per  litre,  which  is  equivalent  to  0-25  per  cent.,  or  1-0837 
grains  per  ounce.  It  thus  very  closely  corresponded  to  the 
results  obtained  by  the  first  method. 

III.  Sir   William  Roberts's  Dilution  Process S1S) — In  this 
plan  nitric  acid  is  used  by  the  contact  method.      The  urine 


METHODS    OF    QUANTITATIVE    ESTIMATION.  15 

is  diluted  with  water  until  it  is  found  that  the  opacity  begins 
to  appear  between  thirty  and  forty-five  seconds  after  the 
fluids  have  come  together.  Each  dilution,  with  an  equal 
quantity  of  water,  represents  what  he  terms  one  degree  of 
albumen,  and  he  finds  that  each  degree  corresponds  to 
0*0034  per  cent.,  or  0*0148  of  a  grain  per  ounce.  By  this 
method  we  found  175  degrees,  which  corresponds  to  2*5 
grains  per  ounce.  Careful  repetitions  of  the  experiment 
confirmed  this  result. 

IV.  Dr.  Oliver's  Percentage  Method.^ — This  method  con- 
sists essentially  in  coagulating  the  albumen  in  urine  by  the 
mercuric  iodide,  or  the  ferrocyanide  of  potassium  test  papers, 
and  diluting  until  it  reaches  an  opacity  exactly  correspond- 
ing to  that  of  a  standard  fluid  enclosed  in  a  tube.  Both 
tubes  are  flattened,  and  are  held  in  front  of  a  white 
card  ruled  with  black  lines,  and  it  is  easy  to  decide 
when  the  lines  are  seen  with  equal  indistinctness  through 
the  two  tubes.  The  standard  fluid  is  arranged  so  as  to 
correspond  to  the  opacity  produced  by  0-l  per  cent,  of 
albumen  when  precipitated  by  the  mercuric  or  the  ferro- 
cyanic  test  papers.  Fifty  minims  of  the  urine  (undiluted  or 
diluted)  are  put  in  the  flattened  test  tube,  reagent  papers  are 
dropped  in,  and  the  contents  are  shaken  up.  The  card  is 
then  placed  behind  the  two  tubes,  and  their  opacities  are 
compared.  If  the  urine  being  tested  is  more  opaque,  water 
is  added  until  the  opacity  of  the  standard  is  reached.  The 
percentage  of  albumen  is  calculated  by  multiplying  0*1  by 
the  number  of  times  the  volume  of  the  urine  (50  minims) 
has  been  increased  by  dilution.  On  applying  this  method 
to  the  urine  which  we  investigated,  we  found  0  64  per  cent, 
of  albumen,  which  corresponds  to  2*8  grains  per  ounce. 

I  have  put  the  results  in  tabular  form  so  as  to  permit  of 
ready  comparison.  It  is,  of  course,  understood  that  the 
same  urine  was  employed  in  each  observation. 


16 


ALBUMINURIA. 


Table  III. — Showing  the  Eesults  obtained  by  different  Methods 
for  Quantitative  Analysis  of  Albumen. 


Grains  per  Ounce. 

I.  Drying  and  weigh- 
ing. 

3-84207  grains  in  100  cc. 

1-0911 

II.  Esbach's  method, 

2'5  grammes   per  litre  ; 
0-25  per  cent. 

1-08375 

III.  Roberts'  method, 

175  degrees. 

2-5 

IV.  Oliver's  percentage 
method. 

0'64  per  cent. 

2-8 

From  our  observations,  it  appears  that  Esbach's  method 
brings  out  results  closely  corresponding  to  those  obtained  by 
the  elaborate  drying  and  weighing  process,  and  I  am  glad  to 
know  that  Dr.  George  Johnson's  observations (18)  have  led  him 
to  the  same  conclusion.  As  the  method  is  easily  worked,  as 
well  as  so  reliable,  it  is  certainly  the  one  which  I  advise  you 
to  adopt,  and  make  yourselves  familiar  with.  Its  only 
disadvantages  are  that  one  must  wait  twenty-four  hours 
before  the  result  can  be  obtained,  and  that  it  does  not 
enable  us  to  measure  less  than  0*5  grammes  per  litre.  The 
methods  of  Roberts  and  Oliver  have  given,  in  our  hands, 
results  closely  corresponding  to  one  another,  but  consider- 
ably different  from  those  obtained  by  separating,  drying,  and 
weighing  ;  and,  therefore,  although  they  give  their  results  at 
once,  I  cannot  so  heartily  commend  them  to  you. 


LECTURE    II. 

ON  THE  INCIDENCE  OF  ALBUMINURIA  AMONG  THE 
PRESUMABLY  HEALTHY. 

Introduction. — Contrariety  of  Opinions. — Questions  to  be  discussed. 
— Is  Albumen  a  Natural  Constituent  of  Urine? — Proportion  of 
presumably  Healthy  People  showing  Albumen. — Method  of  Test- 
ing.— General  Result. — Distinction  between  Soldiers  and  Civil 
Population. — Between  Children  and  Old  People. — Condition  in 
New-born  Infants. — Results  of  Insurance  Experience. — Effects 
of  Diet,  of  Muscular  Exercise,  of  Severe  Exertion,  of  Playing 
Wind  Instruments,  of  Cold  Bathing,  of  Mental  Excitement. — 
Incidence  of  Peptonuria. — Conclusions. 

C\  ENTLEMEN, — I  shall  devote  this  lecture  to  the  discussion 
of  the  question  of  the  incidence  of  albuminuria  among 
the  presumably  healthy.  It  is  one  which  you  will  often  find 
of  great  practical  importance,  in  relation  to  diagnosis  and 
prognosis,  in  the  course  of  your  ordinary  work,  as  well  as  in 
questions  of  life  insurance. 

Great  diversity  of  opinion  exists  as  to  the  frequency  of  the 
occurrence  of  albuminuria  in  healthy  people,  and  elaborate 
inquiries  have  led  different  observers  to  conspicuously  contra- 
dictory conclusions.  Posner(19)  has  said  that  his  observations 
satisfy  him  that  traces  of  albumen  exist  in  every  normal  urine, 
and  may  be  demonstrated  if  sufficiently  delicate  methods  are 
employed.  One  of  the  most  distinguished  authorities  on  the 
subject,  Dr.  Senator  of  Berlin,  says  that  his  observations  supply 
good  reason  why  he  "  should  consider  it  not  improbable  that,  if 
we  were  to    examine   the  urine  for  long  periods  at  different 

17  c 


18  ALBUMINURIA. 

hours  of  the  day,  and  with  great  care,  we  should  sooner  or 
later  find  it  to  contain  albumen  in  the  case  of  every  healthy 
man." (20)  Dr.  Kleudgen,(21)  in  the  course  of  a  special  study  of 
albuminuria  in  relation  to  epilepsy,  came  to  the  conclusion 
that  traces  of  albumen  could  be  demonstrated  in  any  urine 
above  a  certain  degree  of  concentration.  Dr.  de  la  Celle  de 
Chateaubourg (22)  found  albumen  in  the  urine  of  592  out  of  701 
healthy  people  whom  he  examined;  that  is,  in  84  per  cent. 
Dr.  Capitan^23)  found  that  among  98  French  soldiers  44,  or  44 '9 
per  cent.,  had  albuminuria.  Professor  Leube,(24)  on  the  other 
hand,  found  among  119  German  soldiers  whom  he  examined, 
that  only  4  per  cent,  showed  albumen  on  rising  in  the  morning, 
and  16  per  cent,  in  the  forenoon  after  a  march  of  several 
hours'  duration.  Dr.  Van  Noorden(25)  states  that  he  found  it 
vary  under  different  conditions  among  healthy  German  soldiers 
from  3  to  35  per  cent.  Dr.  Munn(26)  found  albuminuria  in  24 
out  of  220 — that  is,  in  10*9  per  cent. — presumably  healthy 
people  examined  for  life  insurance  in  the  United  States  of 
America.  And  Dr.  Leroux(27)  found  it  only  19  times  among 
330  children,  or  in  5 '7 6  per  cent. 

Such  contrariety  of  results  made  me  think  it  desirable 
to  make  a  fresh  series  of  observations  upon  this  point,  with 
the  view  of  determining,  first,  whether  Posner  is  right  in 
saying  that  albumen  is  present  in  every  urine  ;  second,  what 
proportion  of  presumably  healthy  people  have  albumen  in  the 
urine  in  quantity  sufficient  for  demonstration  by  the  tests 
ordinarily  in  use;  and  third,  what  effects  various  physiological 
conditions,  such  as  diet,  exercise,  severe  exertion,  and  cold 
bathing,  produced  upon  the  discharge. 

I  have,  with  the  aid  of  Dr.  Stevens,  made  some  experiments 
with  the  view  of  determining  the  first  of  these  questions,  and 
have  tried  to  repeat  Posner's  observations.  I  do  not  feel  sure 
that  our  results  were  absolutely  satisfactory,  but  the  conclusion 


GROUPS    OF    PEOPLE    EXAMINED.  19 

to  which  I  am  led  in  the  meantime  is,  that  albumen,  if  present 
at  all  in  normal  urine,  is  in  such  extremely  minute  amount  as 
to  be  barely  discernible,  or  not  discoverable  at  all  with  the 
most  delicate  tests,  even  after  considerable  concentration  ;  and 
that,  at  least  in  some  of  the  cases  in  which  minute  traces 
occur,  it  is  accounted  for  not  by  transudation  with  the  urine 
but  by  the  after-addition  of  epithelial  and  other  cellular 
elements  from  the  urinary  passages. 

With  the  view  of  obtaining  evidence  as  to  the  second 
question — that  is,  the  proportion  of  presumably  healthy  people 
who  have  albumen  in  their  urine  in  quantity  sufficient  for 
demonstration  by  the  tests  ordinarily  in  use,— -I  have  examined, 
with  the  assistance  of  Drs.  Stevens  and  Boddie,  several 
series  of  presumably  healthy  individuals.  By  the  kindness  of 
Dr.  Mills  and  Dr.  Fayrer,  medical  officers  of  Edinburgh  Castle, 
and  of  the  Colonel  and  Adjutant  of  the  Seaforth  Highlanders, 
I  was  enabled  to  examine  a  series  of  205  soldiers  and 
applicants  for  admission  to  the  army.  I  also  got  specimens 
of  urine  from  100  healthy  male  adults  engaged  in  civil  employ- 
ments. By  the  kindness  of  Dr.  Sinclair  and  his  resident 
assistant  Dr.  Helme,  I  examined  150  (100  being  men  about 
or  above  60,  and  50  children),  healthy  inmates  of  Craig- 
lockhart  Poorhouse  ;  and  by  the  kindness  of  Dr.  Halliday 
Douglas  and  Mr.  Munro,  I  had  opportunity  of  examining  the 
urine  of  a  large  number  of  the  inmates  of  the  Orphan  Hospital. 
We  had  thus  in  all  505  presumably  healthy  individuals,  with 
regard  to  whose  urine  we  made  the  most  careful  examination, 
sometimes  on  one,  sometimes  on  several  occasions. 

The  plan  of  testing  adopted  was  in  all  cases  the  same. 
Urines  which  were  cloudy  from  any  cause  were  carefully 
filtered.  Those  which  were  clear  were  tested  as  passed.  Each 
specimen  was  tested  first  with  nitric  acid  by  the  contact 
method,   by  which,    as   previous   experiment   had   shown,  we 


20 


ALBUMINURIA. 


could  discover  albumen  in  the  proportion  of  0  003  per  cent., 
or  0  0 1 3 1 1  of  a  grain  per  ounce  ;  and  by  picric  acid,  using 
the  contact  method,  by  which  we  could  discover  albumen  in 
the  proportion  of  0*00015  per  cent.,  or  0*0006555  of  a  grain 
per  ounce.  Each  specimen  was  also  carefully  tested  for  pep- 
tones, using  Fehling's  solution  by  the  contact  method,  a  plan 
which  certainly  shows  the  presence  of  peptones  very  distinctly 
when  they  are  added  to  urine,  and  is  regarded  a  reliable  test  in 
cases  of  peptonuria. 

Taking  specimens  of  urine  passed  by  505  presumably 
healthy  individuals,  during  the  forenoon  or  about  midday, 
we  found  that  albumen  was  present  in  166,  or  a  little  over 
32*8  per  cent.  Of  these  it  was  in  quantity  sufficient  to  be 
discovered  by  the  cold  nitric  acid  test  in  76,  or  15  '5  per  cent. 
In  Table  IV.  the  general  results  are  shown — 


Table  IV. — Showing  incidence  op  Albuminuria  in  505  presumably 
Healthy  Individuals  (forenoon  or  noon  specimens). 


Urines 
Examined. 

Albumen  shown 
by  HN03. 

Albumen  shown 
by  Picric  Acid. 

Total. 

Per  cent. 

505 

76 

90 

166 

32*8 

But  it  was  evident  that  a  marked  difference  existed  between 
various  groups  of  individuals  examined,  as  between  soldiers  and 
men  of  corresponding  age  following  civil  occupations,  and  be- 
tween children  and  men  about  or  above  sixty  years  old.  It  is 
therefore  necessary  to  consider  these  groups  separately.  Among 
the  soldiers  and  recruits  examined,  205  in  number,  77,  or 
37*56  percent.,  had  albuminuria;  while  of  100  adults  in  civil 
employments,  10  showed  the  symptom.  Of  the  former  group 
it  was  shown  by  nitric  acid  in  47,  or  22*92  per  cent. ;  by  picric 
acid  only  in  30,  or  14*63  per  cent.  Of  the  latter  group  it  was 
shown  by  nitric  acid  in  7,  or  7  per  cent. ;  by  picric  acid  only 
in  3,  or  3  per  cent.      Table  V.  shows  these  results — 


RELATIONS    TO   AGE. 


21 


Table  V. — Showing  the  incidence  of  Albuminuria  in  Soldiers 
and  Civil  Population. 


With  HN03. 

Si£Kc  |    Total- 

Per  cent. 

Soldiers,      .     .     205 

Civil  Popula-  )     ,flg 
tion,  .     .     .  ) 

47 

7 

30                    77 
3                     10 

37-56 
10 

In  seeking  to  compare  the  facts  in  the  case  of  children  and 
old  people,  I  thought  it  desirable  to  get  access  to  individuals 
in  similar  position  in  life,  and  living  under  somewhat  similar 
conditions,  and  I  was  glad  to  avail  myself  of  the  opportunity 
afforded  of  examining  the  inmates  of  Craiglockhart  Poorhouse 
and  the  Orphan  Hospital,  We  got  specimens  of  the  urine  of 
100  men,  about  or  above  sixty  years  of  age,  resident  in  the 
poorhouse,  but  not  on  the  sick  list.  I  found  that  albumen  was 
present  in  62  of  them.  We  also  examined  a  series  of  100 
healthy  children  of  various  ages,  and  found  that  it  was  present 
in  17.  Nitric  acid  showed  it  in  17  of  the  old  men,  picric 
acid  in  other  45  ;  while  in  the  children,  nitric  acid  showed  it 
in  5,  and  picric  acid  in  other  12. 

When  these  results  are  shown  in  a  tabular  form,  we  see  at 
a  glance  how  striking  is  the  contrast  between  the  two  groups. 


Table  VI. — Showing  incidence  of  Albuminuria  in  100  Children, 
Inmates  of  Craiglockhart  Poorhouse,  and  50  of  the 
Orphan  Hospital,  and  100  Old  People  (all  presumably 
healthy),  Inmates  of  Craiglockhart  Poorhouse. 


With  HN03. 

With  Picric 
Acid. 

Total. 

Per  cent. 

Children, 

People      about      or  ) 
above  sixty,        .  ) 

5 

17 

12 
45 

17 
62 

17 
62 

22  ALBUMINUKIA. 

It  thus  appears  that  of  the  four  groups  the  old  men  in  the 
poorhouse  showed  albuminuria  most  frequently,  the  soldiers 
next,  the  children  in  the  poorhouse  next,  and  the  least 
frequently  affected  were  the  young  men  engaged  in  civil 
occupations. 

As  it  has  been  asserted  that  the  urine  of  newly  born 
children  is  always  albuminous,  we  obtained  specimens  from 
twelve  infants  in  the  Maternity  and  Simpson  Memorial  Hospital, 
and  found  that  two  showed  albumen  with  nitric  acid,  and 
three  showed  a  very  faint  trace  with  picric  acid.  Our  results 
indicate  that  albuminuria  is  not  universal,  but  that  traces  are 
not  unfrequently  present  during  the  first  days  of  life. 

It  was  not  in  my  power  to  determine  the  cause  of  the  albu- 
minuria in  the  persons  examined,  but  I  took  care  to  exclude 
cases  due  to  accidental  contamination  with  pus,  and  in  only  four 
cases  had  I  any  reason  to  think  that  I  might  have  admitted 
such — viz.,  two  soldiers  and  two  of  the  old  men.  In  none  of 
the  cases  was  the  albuminuria  due  to  cardiac  or  pulmonary 
diseases,  and  in  very  few  was  there  occasion  to  suspect  the 
existence  of  Bright' s  disease.  On  the  other  hand,  there  were 
few  cases  whose  clinical  history  corresponded  to  Pavy's  cyclical 
albuminuria  or  Moxon's  albuminuria  of  adolescents. 

Being  anxious  to  supplement  these  observations,  I  asked 
two  of  my  former  assistants,  who  are  well  known  to  me  as 
careful  and  accurate  observers,  Dr.  James  Ritchie  and  Dr. 
Graham  Brown,  to  give  me  the  results  as  to  albuminuria  met 
with  in  the  last  200  cases  which  had  proposed  for  insurance 
in  the  two  companies  for  which  they  are  medical  referees. 
The  tests  employed  had  been  heat  or  cold  nitric  acid,  and  it 
was  found  that  in  one  series  of  200,  5  per  cent,  showed  albu- 
men, and  in  the  other  series  only  1  per  cent,  did  so.  The 
former  result  corresponds  pretty  closely  to  what  nitric  acid 
revealed  in  my  own  series  of  young  men  following  civil 
employments,  but  is  considerably  below  the  results  brought 


ACTION    OF    PHYSIOLOGICAL    CONDITIONS.  23 

out  by  Dr.  Munn  in  his  American  statistics.  The  second 
series  gives  a  much  lower  percentage. 

It  is  interesting  to  compare  the  results  obtained  in  my 
other  categories  with  those  given  by  other  observers.  Leube 
found  among  German  soldiers  examined  during  the  forenoon 
and  after  marching,  16  per  cent,  albuminuric.  Van  Noorden, 
under  like  conditions,  found  it  in  35  per  cent.  Capitan  found 
it  among  French  soldiers  44*9  per  cent.,  and  I  have  found  it 
among  the  Highlanders  (including  recruits)  in  37 '5 5  per  cent. 

The  Craiglockhart  and  Orphan  Hospital  children  gave  a 
result  less  favourable  than  that  obtained  by  Leroux,  for  while 
he  found  albuminuria  in  only  5-76  per  cent.,  I  found  it  in  17. 

I  am  not  aware  of  the  publication  of  any  series  of  observa- 
tions on  old  men  corresponding  to  my  Craiglockhart  series. 

In  answer,  then,  to  our  second  question,  it  appears  that  a  trace 
of  albumen  may  be  discovered  by  delicate  tests  in  the  urine 
of  nearly  1  in  3  of  the  male  population,  if  it  be  examined 
during  the  active  period  of  the  forenoon,  an  hour  or  two  after 
breakfast,  although  before  breakfast  the  proportion  would  be 
considerably  smaller. 

The  third  question  is  as  to  the  effects  produced  by  diet, 
exercise,  severe  exertion,  and  cold  bathing  upon  the  discharge 
of  albumen. 

In  order  to  determine  the  effects  of  diet,  I  obtained  speci- 
mens of  the  urine  of  32  soldiers  before  and  after  breakfast, 
and  found  that  of  these  5,  or  15 '6  2 5  per  cent.,  had  albumin- 
uria on  rising  in  the  morning  ;  while  13,  or  40*525  per  cent., 
showed  it  after  the  morning  meal.  Thus  8,  or  25  per  cent., 
who  had  not  had  albuminuria  in  the  morning,  acquired  it  after 
breakfast. 

Among  40   old  men  examined  in  Craiglockhart  Poorhouse 
we   found  that   15,   or  37*5   per  cent.,    showed  albuminuria- 
before  breakfast ;    while   after  that   meal  27,    or    6 7" 5    per 


24 


ALBUMINURIA. 


cent.,  showed  it.  Thus  12  who  had  not  had  albuminuria  on 
rising  in  the  morning  acquired  it  after  breakfast. 

Among  40  children,  we  found  that  5,  or  12  5  per  cent., 
showed  it  before  breakfast,  and  7,  or  17 '5  per  cent.,  showed 
it  after  breakfast.  Thus  2  who  had  not  albuminuria  on  rising 
in  the  morning  acquired  it  after  breakfast. 

Among  48  boys,  inmates  of  the  Orphan  Hospital,  we  found 
that  before  breakfast  albumen  was  present  in  7,  or  14 '6  per 
cent;  after  breakfast,  in  10,  or  20 '8 3  per  cent. 

Taking  the  four  groups  together,  we  have  a  series  of  160 
cases  examined  before  and  after  breakfast,  and  we  find  that  of 
these  32,  or  20  per  cent.,  discharged  albumen  before  break- 
fast, while  57,  or  35*6  per  cent.,  showed  it  after  the  meal. 


Table  VII. — Showing  the  Influence  op  Breakfast  on  the 
Discharge  of  Albumen  from  the  Kidneys. 


No. 

Before  Breakfast. 

After  Breakfast. 

Soldiers,  . 
Old  Men, 
Children  . 

(Craiglockhart). 
Children  . 

(Orphan  Hospital). 

Total, 

32 
40 
40 

48 

No. 

5 
15 

5 

7 

Per  cent. 
15-625 
37-5 
12-5 

14-6 

No. 
13 

27 

7 

10 

Per  cent. 
40-625 
67-5 
17-5 

20-83 

160 

32 

20 

57 

35-6 

I  have  put  these  various  results  in  a  tabular  form,  which 
shows  very  clearly  that  at  all  ages,  and  in  the  various  con- 
ditions investigated,  the  taking  of  breakfast  is  followed  by  an 
increased  frequency  of  albuminuria,  but  that  the  increase  is 
greatest  among  the  old  men  and  the  soldiers. 

In  connection  with  this  it  is  worthy  of  notice  that  in  most 
of  the  cases  of  after-breakfast  albuminuria,  the  quantity  of 
albumen  was  too  minute  to  be  shown  by  the  cold  nitric  acid 
test,  and  also  that  when  it  was  present  before,  it  was  generally 


EFFECT    OF    FOOD    AND    EXERCISE.  25 

increased  in  amount  after  the  meal.  But  on  the  other  hand, 
there  were  two  cases  among  the  children  in  which  breakfast 
was  followed  by  the  disappearance  of  albuminuria  which  had 
been  present  on  rising.  I  have  met  with  facts  corresponding 
to  this  in  some  of  my  albuminuric  patients.  A  gentleman 
who  is  at  present  under  my  care,  for  example,  shows  copious 
albumen  in  morning  urine,  and  a  comparatively  small  quantity 
after  breakfast. 

Contrary  to  what  one  might  expect,  considering  what  is 
usually  taken  for  breakfast  as  compared  with  what  is  taken 
for  the  other  meals,  it  appears  that  breakfast  more  frequently 
induces  albuminuria,  or  an  increase  of  albumen,  than  the 
others.  The  attempt  to  explain  the  influence  of  food  in  this 
respect,  raises  problems  of  considerable  difficulty.  But  I  shall 
not  at  present  seek  to  determine  whether  an  alteration  of 
the  blood,  or  the  blood  pressure,  or  of  the  vascular  walls, 
or  epithelial  structures  is  the  cause. 

It  may  also  be  remarked  that  the  mucin  in  the  urine 
likewise  increases  after  food,  although  not  to  the  same  extent 
as  the  albumen. 

The   next   point   investigated  was  the   effect   of  muscular 

exercise  on  albuminuria.  It  appeared  desirable  to  distinguish 
between  the  effects  of  moderate  exercise  and  of  severe  and 
prolonged  exertion.  Observations  were  therefore  made  upon 
soldiers  before  and  after  their  weekly  march  of  seven  to  ten 
miles,  and  before  and  after  the  fatigue  duty  of  coal-carrying. 

Of  63  soldiers  about  to  start  for  their  weekly  march  of 
from  seven  to  ten  miles  in  heavy  marching  order,  18,  or  29 
per  cent.,  were  found  to  have  albumen  in  their  urine.  After 
their  march,  the  urines  of  58  of  these  men  were  examined, 
and  11,  or  19  per  cent.,  showed  albumen.  The  march  out, 
therefore,  distinctly  diminished  the  albuminuria.  But  as  the 
march  is  taken  in  the  forenoon,  it  occurred  to  me  that  some 
of  those   who   got  rid    of   the    symptom  during    the    march 


2  6  ALBUMINURIA. 

might  have  had  a  temporary  albuminuria  induced  by  break- 
fast. I  therefore  examined  the  urine  of  32  soldiers  before 
breakfast,  after  breakfast,  and  on  their  return  from  the  march. 
It  was  found  that  before  breakfast  albumen  was  present  in  5, 
or  15  6 2 3  per  cent.;  after  breakfast  in  13,  or  40*625  per 
cent.;  and  after  the  march  in  9,  or  28*125  per  cent.  It 
was  noticed  also  that  in  several  cases  the  amount  of  albumen 
diminished,  although  it  did  not  wholly  disappear.  It  was 
thus  shown  that  in  a  considerable  proportion  of  cases  the 
march  removed  the  dietetic  albuminuria,  and  other  observa- 
tions which  I  have  made  justify  the  conclusion  that  the 
march  out  exerts  a  favourable  influence.  It  must,  however, 
be  observed  that  in  some  individuals  the  march  induced  albu- 
minuria. In  one  of  the  nine  cases  it  occurred  only  after 
the  march,  the  urine  having  been  quite  free  from  albumen  on 
rising  and  after  breakfast,  and  in  at  least  one  other  case  the 
amount  of  albumen  was  distinctly  less  after  breakfast  than 
it  was  after  the  inarch.  It  is  thus  clear  that  the  effort  of 
marching  is  sufficient  to  induce  the  symptom  in  some  people. 

But  while  marching  proved  on  the  whole  beneficial,  fatigue 
duty  of  coal-carrying  brought  out  a  very  different  result. 
This  work,  as  carried  on  in  Edinburgh  Castle,  obliges  two 
men  to  carry  a  bucket  containing  80  lbs.  of  coal  for  several 
hundred  feet  up  a  rather  steep  incline,  and  then  up  barrack 
stairs  to  the  different  floors.  Each  pair  of  soldiers  makes  six 
or  seven  such  journeys  during  the  forenoon  in  which  they  are 
told  off  to  this  duty.  Of  36  soldiers  engaged  in  this  work  we 
found  that  16,  or  44  per  cent.,  had  albuminuria  before  the 
labour  commenced  ;  while  23,  or  64  per  cent.,  had  albumen 
at  the  end  of  it.  On  another  day,  when  we  were  able  to 
get  the  urine  of  17  men  engaged  in  this  coal-carrying,  7  had 
albuminuria,  equal  to  a  little  over  41  per  cent,  although  the 
observations  were  made  not  at  the  end,  but  in  the  course 
of  their  work. 


EFFECTS    OF    SEVERE   EXERTION. 


27 


I   have   put   in   tabular    form    the    facts    elicited    in    this 
connection. 

Table  VIII.  —  Showing  effects  of  Exercise  and  of  severe 
Exertion,  also  of  Breakfast  and  Exercise. 


No.  Examined. 

Before. 

After. 

March  of  8  miles, 

Before. 
63 

After. 
58 

No. 
18 

P.  cent. 
29 

No. 
11 

P.  cent. 
19 

Fatigue      duty — 
coaling,     . 

36 

36 

16 

44 

23 

64 

Breakfast        and 
march, 

32 

32 

Before 
5 

Br'fast. 
15-6 

After  ] 
13 

Jr'fast. 
40-6 

After  March. 
9     1    28-1 

In  regard  to  the  effect  of  violent  exercise,  I  have  thought  it 
well  to  make  another  investigation,  in  order  to  get  confirma- 
tion, if  possible,  of  the  result  brought  out  by  the  coal  carrying, 
and,  by  the  kindness  of  Mr.  Munro,  I  have  succeeded  in 
obtaining  this  at  the  Orphan  Hospital.  The  result  is  given 
in  Table  IX. 


Table  IX. — Showing  the  Influence  of  Violent  Exercise  (playing 
Football  for  an  Hour)  on  the  Incidence  of  Albuminuria. 

Meal  of  Bread  and  Milk  at  5.45  p.m.     Football  from  7.30  to  8.30  p.m. 


Before  Football— 7.30. 

After  Football— between  8.30  and  9. 

No. 

With 

hno3. 

Picric 
Acid. 

Total. 

Per 

cent. 

With 
HN03. 

Picric 
Acid. 

Total. 

Per 
cent. 

25 

0 

1 

1 

4 

3 

12 

15 

60 

Twenty-five  boys  played  very  actively  at  football  for  an 
hour,  one  evening.  Their  supper,  which  consisted  of  bread 
and  milk,  was  taken  at  5.45  P.M.,  and  they  played  football 
from  7.30  to  8.30.      A  specimen  of  urine  was  obtained  from 


28  ALBUMINURIA. 

each  boy  before  and  after  the  game.  You  will  observe  that 
the  result  quite  corresponds  with  that  obtained  at  the  Castle. 
Indeed,  the  effect  is  even  more  apparent.  None  of  the  first 
set  of  specimens  showed  any  albumen  with  nitric  acid.  Three 
of  the  second  series  showed  unmistakable  evidence  with  that 
test,  none  of  these  having  before  the  exercise  reacted  distinctly 
even  with  picric  acid.  In  only  one  case  was  there  any  distinct 
trace  of  albumen  with  picric  acid  before  the  game,  while  after 
it  fifteen  showed  albumen  with  that  reagent.  You  will 
observe,  further,  that  this  experiment  confirms  the  view  that 
it  is  only  a  slight  albuminuria  which  is  produced  by  violent 
exercise  in  healthy  people. 

From  the  facts  thus  given  it  is  shown  that  violent  exertion 
may  produce  albuminuria,  while  moderate  exercise  tends  rather 
in  many  cases  to  diminish  it.  Statements  have  been  made  as 
to  the  urine  of  the  performers  of  pedestrian  feats  which  confirm 
this  experience.  Weston's  urine  is  said  to  have  contained 
both  albumen  and  tube  casts  at  the  end  of  one  of  his 
prolonged  walks. 

A  very  interesting  observation  has  been  made  by  Dr.  W. 
A.  Stirling/28*  in  a  thesis  sent  in  for  the  M.D.  degree  this 
year,  and  he  has  permitted  me  to  make  use  of  it  on  this 
occasion.  He  found  in  the  course  of  an  investigation  as  to 
the  incidence  of  albuminuria  in  369  boys,  who  are  being 
educated  in  the  training-ship  at  Grays,  Essex,  that  the  boys 
who  played  wind  instruments  in  the  band  exhibited  albumin- 
uria in  a  much  larger  proportion  than  the  others.  Thus, 
while  out  of  64  boys  so  employed,  38,  or  5  9 '4  per  cent.,  had 
albuminuria,  out  of  305  boys,  otherwise  under  like  conditions, 
but  not  in  the  band,  only  39,  or  12*8  per  cent.,  showed  the 
symptoms. 

These  results  may,  as  he  remarks,  be  very  naturally  referred 
to  altered  blood  pressure  due  to  habitual  use  of  musical  instru- 
ments. 


CONCLUSIONS. 


29 


With  the  view  of  testing  this,  I  examined  24  boys  who  play- 
wind  instruments  in  the  band  of  the  Orphan  Hospital,  and  24 
boys  in  that  Institution  who  are  otherwise  similarly  placed, 
except  in  not  being  members  of  the  band.  It  appears,  so  far  as 
the  numbers  serve  us  for  the  purpose,  that  albuminuria  is  more 
frequent  among  the  band  boys  than  among  the  others  ;  but 
that  there  is  a  diminution  rather  than  increase  at  the  end  of 
an  hour's  practice  with  the  instruments.  I  have  put  the  facts 
in  tabular  form,  and  it  is  clear  that  no  such  discrepancy  exists 
as  in  the  training-ship  boys  ;  but  still  the  statistics  lend  a 
certain  measure  of  support  to  Dr.  Stirling's  observations. 


Table  X.  —  Showing  Incidence  of  Albuminuria  in  24  Wind- 
Instrument  Band  Boys,  and  24  other  Boys  (Orphan 
Hospital). 


No. 

Before  Breakfast. 

After  Breakfast  and  Playing. 

After  Playing,  5  p.m. 

Band  Boys, 

24 

HN03. 

2 

Pic.  A. 
3 

Tot. 

5 

P.C. 

20-8 

HNO  . 

3 

2 

Pic.  A. 
4 

Tot. 
6 

P.C. 
25-0 

HN03. 
1 

Pic.  A. 
2 

Tot. 
3 

P.C. 

12-5 

Other  Boys, 

24 

0 

2 

2 

8-3 

1 

3 

4 

16*6 

Some  years  ago  Dr.  George  Johnson (29)  of  London  drew  atten- 
tion to  the  fact  that  albuminuria  is  sometimes  induced  by  cold 
bathing.  In  order  to  get  further  information  upon  this  ques- 
tion, I  got  from  21  boys  the  urine  which  they  passed  on  rising 
at  6  A.M.,  and  that  passed  at  8  after  a  cold  plunge  bath.  It 
was  found  that  while  before  bathing  4,  or  19*05  per  cent., 
showed  albumen ;  after  it  5,  or  23'8  per  cent.,  showed  it. 

Among  the  boys  so  examined  only  a  small  number  showed 
albuminuria,  and  the  amount  of  albumen  was  slight,  for  nitric 
acid  failed  to  detect  it,  but  there  was  an  increase  both  in  the 
number  of  cases  affected  and  in  the  intensity  of  the  con- 
dition, although  the  effect  was  not  very  pronounced. 


30 


ALBUMINURIA. 


In  Table  XI.  I  have  stated  the  results  of  these   observa- 
tions. 


Table  XI. — Showing  Effect  of  Cold  Bathing  on  21  Boys 
(Orphan  Hospital). 


Before  Bath  (6  a.m.). 

After  Bath  (8  a.m.). 

With 
HN03. 

Only  with 
Pic.  A. 

Total. 

Per  cent. 

With 
HN03. 

Only  with 
Pic.  A. 

Total. 

Per  cent. 

0 

4 

4 

19-05 

0 

5 

5 

23-08 

I  have  not  been  able  as  yet  to  test  the  effects  of  mental 
excitement  or  emotion  upon  any  considerable  number  of 
healthy  individuals,  but  no  doubt  an  investigation  in  suitable 
quarters  might  elicit  interesting  results.  This  is  indicated  by 
the  occurrence  of  such  cases  as  that  recorded  by  Furbringer/30) 
of  a  medical  man  who  never  showed  albuminuria  as  the  result 
of  long  and  fatiguing  wTork,  nor  from  the  use  of  a  diet  rich  in 
albumen,  nor  from  the  free  use  of  alcohol,  but  constantly 
showed  it  in  large  amount  when  exposed  to  mental  excite- 
ment with  depression. 

The  remarks  which  I  have  made  apply  only  to  the  ordinary 
forms  of  proteid  serum-albumen  and  serum-globulin.  With 
regard  to  the  occurrence  of  peptones,  we  discovered  them  in 
only  3  out  of  the  whole  series  of  771  specimens,  which  were 
carefully  examined  in  the  course  of  the  investigations. 

From  the  facts  recorded,  we  seem  entitled  to  conclude — 

1.  That  there  is  no  sufficient  proof  that  albumen  is  normally 
discharged  from  the  human  kidneys. 

2.  That  albuminuria  is  much  more  common  among  presum- 
ably healthy  people  than  was  formerly  supposed,  being  demon- 
strable by  delicate  tests  in  nearly  one-third  of  those  examined. 

3.  That  the  existence  of  albuminuria  is  not  of  itself  a  suffi- 
cient ground  for  the  rejection  of  a  proposal  for  life  insurance. 


CONCLUSIONS.  3 1 

4.  That  traces  of  albumen  are  not  unfrequently  present  in 
the  urine  passed  during  the  first  days  of  life. 

5.  That,  excepting  as  above  shown,  the  frequency  of  albu- 
minuria increases  as  life  advances  ;  being  rare  in  children  and 
young  adults,  and  common  in  men  at  or  above  sixty  years  of 
age. 

6.  That  it  is  more  common  among  those  whose  occupations 
involve  arduous  bodily  exercise  than  among  those  who  have 
easy  work. 

7.  That  albuminuria  frequently  follows  the  taking  of  food, 
especially  of  breakfast. 

8.  That  moderate  muscular  effort  rather  diminishes  than 
increases  albuminuria,  except  in  rare  cases. 

9.  That  violent  or  prolonged  exertion  often  induces  albu- 
minuria. 

10.  That  cold  bathing  produces  or  increases  it  in  some 
individuals. 

11.  That  the  discharge  of  peptones  from  the  kidneys  is 
exceedingly  rare  in  the  presumably  healthy. 


LECTURE    III. 

ON  THE  INCIDENCE  OF  ALBUMINURIA  AMONG 
THE  SICK. 

Introduction. — Series  of  Cases  Examined. — Method  Adopted. — General 
Results  in  Different  Groups. — Categories  of  Causes  Defined. — 
Series  of  Cases  taken  together. — Series  of  Private  Cases. — 
Series  of  Indoor  Hospital  Cases. — Outdoor  Hospital  Cases. — 
Patients  in  Royal  Hospital  for  Sick  Children. — Fever  House 
Patients. — Alcoholic  Cases. — General  Conclusions  as  to  Incidence 
of  Serum  Albumen. — Peptonuria  in  the  Different  Series. 

C\  ENTLEMEN, — Having  shown  yon  the  results  which  have 
been  obtained  as  to  the  incidence  of  albuminuria 
among  the  presumably  healthy,  I  intend  to-day  to  bring 
before  you  the  results  of  a  series  of  observations  which  I 
have  made  as  to  its  incidence  among  various  groups  of 
patients  to  which  I  have  had  access. 

I  have  made  careful  investigation  in  regard  to  150 
consecutive  private  patients  as  they  presented  themselves  in 
my  practice  ;  150  consecutive  cases  under  my  care  in  the 
wards  of  the  Royal  Infirmary;  100  patients  applying  con- 
secutively for  advice  as  out-patients  at  my  department ;  5  0 
patients  in  the  wards  of  the  Royal  Hospital  for  Sick 
Children  ;  40  cases  in  Ward  VI. ,  which  is  mainly  devoted  to 
the  treatment  of  patients  suffering  from  alcoholism  ;  50 
patients  under  treatment  in  the  Fever  Hospital ;  and  25 
cases  of  women  who  had  been  confined  in  the  Maternity 
Hospital. 

32 


INCIDENCE    IN    GROUPS    OF   PATIENTS. 


33 


For  their  kindness  in  providing  me  with  facilities  for 
carrying  on  this  work,  I  am  indebted  to  the  physicians  of 
the  Sick  Children's  Hospital ;  to  Dr.  Smart,  the  physician  in 
charge  of  Ward  VI.  ;  to  Drs.  Allan  Jamieson  and  Wood,  of 
the  Fever  Hospital ;  and  to  Professor  Simpson  and  Dr.  Hart, 
who,  at  the  time  the  observations  were  made,  were  on  duty 
as  physicians  to  the  Maternity. 

In  each  case  the  urine  was  examined  with  nitric  acid, 
picric  acid,  and  Fehling's  solution.  In  the  case  of  the 
patients  belonging  to  the  first  five  categories,  a  single 
specimen  was  examined.  In  the  Fever  House  cases  we 
obtained  specimens  of  the  urine  passed  on  the  day  on  which 
it  seemed  most  likely  that  albumen  would  be  found  in  each 
variety  of  fever.  In  the  puerperal  cases,  Dr.  Stevens  under- 
took a  specially  careful  inquiry,  with  the  view  of  testing  the 
correctness  of  certain  statements  as  to  the  occurrence  of 
peptones  in  the  puerperal  condition.  He  obtained  speci- 
mens of  the  urine  of  some  patients  before  the  confinement, 
and  of  all  during  several  days  after  the  confinement, 
every  precaution  being  taken  to  protect  the  specimens  from 
accidental  contamination. 

In  the  following  table  are  shown  the  number  and  percen- 
tage of  cases  showing  albuminuria,  those  showing  it  with 
nitric  acid,  and  those  with  picric  acid. 

Table  XII. — Showing  the  Incidence  of  Albuminuria  in 
Groups  of  Patients. 


No. 

With  HN03 

Picric  Acid. 

Total. 

Percent. 

Private  Patients, .... 

150 

27 

9 

36 

24 

Indoor  Infirmary  Patients,  . 

150 

53 

21 

74 

49.3 

Outdoor  Infirmary  Patients, 

100 

16 

3 

19 

19 

Royal  Hospital  for  Sick  Children, 

50 

3 

4 

7 

14 

Fever  Hospital,    .... 

50 

18 

15 

33 

66 

Maternity  Hospital, 

25 

13 

5 

18 

72 

It  thus  appears  that  among  the  private  patients  36,  or  24 

D 


34  ALBUMINURIA. 

per  cent.,  showed  albumen  ;  among  the  indoor  Infirmary 
patients,  74,  or  4 9 '3  per  cent.  ;  among  the  outdoor  Infir- 
mary patients,  19  per  cent.  ;  and  among  the  sick  children, 
7,  or  14  per  cent.  ;  among  the  fever  cases,  33,  or  66  per 
cent.  ;  among  the  Maternity  Hospital  cases,  18,  or  72  per 
cent.  In  the  three  first  groups  the  amount  of  albumen  was 
more  frequently  large  enough  to  be  discovered  by  the  cold 
nitric  acid  test, — nitric  acid  showing  it  in  27  of  the  private 
patients,  picric  acid  only  in  other  9  ;  nitric  acid  in  53  of  the 
indoor  patients,  picric  acid  in  other  21  ;  nitric  acid  in  16  of 
the  outdoor  patients,  picric  acid  in  other  3  ;  and  among  the 
sick  children,  nitric  acid  in  3,  picric  acid  in  other  4. 

Now,  it  may  he  held  that  the  150  private  patients  were 
placed  under  conditions  pretty  much  corresponding  to  those 
of  the  presumably  healthy  civil  population  referred  to  in  the 
last  lecture,  and  the  proportion  of  24  per  cent,  among  the 
sick,  and  10  "8  per  cent,  among  the  presumably  healthy, 
seems  such  as  one  would  expect.  The  indoor  Infirmary 
patients  may  be  said  to  correspond  in  a  general  way,  as  to 
occupation  and  circumstances,  to  what  we  find  in  the  pre- 
sumably healthy  soldiers  ;  and  we  find  49*3  per  cent,  in  the 
hospital,  as  against  37*56  per  cent,  among  the  soldiers.  The 
difference  is  not  so  great  as  one  might  have  expected ;  but 
allowance  must  be  made  for  the  fact  that  Infirmary  patients 
are  in  much  more  favourable  conditions  in  respect  of  exercise 
and  diet  than  are  the  soldiers  and  recruits,  and  so  probably 
often  escape  minor  degrees  of  albuminuria,  to  which  they 
would  be  liable  if  they  were  following  their  ordinary 
lives  of  labour.  The  outdoor  Infirmary  patients  represent  a 
somewhat  different  class,  many  of  them  being  women  engaged 
in  sedentary  occupations  ;  and  accordingly  one  is  prepared 
to  find  them  occupying  a  position  intermediate  between  that 
of  the  ordinary  civil  population  on  the  one  hand  and  the 
soldiers  and  indoor  hospital  group  on  the  other.      The  fact 


DEFINITION    OF    GROUPS.  35 

that  the  percentage  among  them  was  only  19,  while  among 
my  house  patients  it  was  24,  may  perhaps  be  explained  by 
the  circumstance  that  my  proportion  of  renal  cases  among 
the  latter  is  considerable.  The  Sick  Children's  Hospital 
cases  bring  out  a  result  more  favourable  than  could  have 
been  anticipated,  only  14  per  cent,  showing  albumen  ;  while 
among  the  Craiglockhart  and  Orphan  Hospital  children 
17  per  cent,  showed  it.  I  am  not  prepared  to  offer  a 
satisfactory  explanation  of  this  fact,  and  therefore  simply 
record  it  with  the  remark  that  probably  the  rest  and  quiet 
of  the  life  in  the  Sick  Children's  Hospital  affords  the 
explanation. 

With  regard  to  the  observations  in  the  puerperal  cases, 
the  interest  turns  chiefly  upon  the  question  of  the  peptones, 
and  I  shall  speak  of  that  at  the  end  of  this  lecture  ; 
but  with  regard  to  serum  albumen  it  may  be  noted  that  it 
was  present  in  1  of  the  2  cases  tested  before  labour  com- 
menced, in  2  out  of  3  tested  on  the  day  of  labour,  in  1 2  out 
of  17  tested  on  the  second  day,  in  8  out  of  15  tested  on  the 
third,  in  6  out  of  12  tested  on  the  fourth,  in  5  out  of  13 
tested  on  the  fifth,  and  in  6  out  of  S  tested  on  the  sixth  ; 
and  that  in  no  case  was  there  reason  to  believe  that  serious 
renal  inflammation  existed.  Certainly  there  never  was 
ground  for  anxiety  in  any  of  the  series  of  cases,  except  in 
one  who  was  suffering  from  phthisis. 

My  object  in  this  research  was  not  merely,  as  in  the  case 
of  the  presumably  healthy,  to  determine  the  frequency  of  the 
incidence  of  the  symptom,  but  also  to  make  out  its  causes. 
And  I  found  that  the  causes  were  referable  to  a  series  of 
categories.      Let  me  explain  what  these  categories  are  : 

1.  Bright' s  Disease. — Under  this  head  I  have  included  all 
cases  referable  to  any  of  the  forms  of  renal  disease,  including 
inflammation  of  the  tubules,  stroma,  and  Malpighian  bodies, 
the  chronic  cirrhotic  process,  and  waxy  degeneration,  with 


3  6  ALBUMINURIA. 

their  various  combinations,  and  even  the  slighter  inflamma- 
tory changes  which  so  commonly  occur  in  the  course  of 
other  diseases. 

2.  Probably  Bright  s  Disease. — This  category  includes  the 
cases  in  which  our  investigations  left  a  margin  of  doubt  as  to 
whether  structural  organic  change  of  the  kidney  was  really 
present  or  not. 

3.  Febrile  Albuminuria. — A  category  of  much  clinical  im- 
portance, including  fevers,  inflammations,  acute  rheumatism, 
and  other  diseases  with  high  temperature.  This  category 
passes  by  insensible  gradations  into  the  first,  but  I  have 
sought  to  determine  their  position  by  careful  investigation  of 
each  individual  case. 

4.  Vascular  Albuminuria. — This  group  includes  cases 
in  which  the  albumen  appears  to  result  from  changes  in  the 
circulation  in  the  kidney,  where  the  outflow  is  hindered  by 
increased  backward  pressure  from  disease  of  the  heart  or  of 
the  lungs,  or  where  the  circulation  is  altered  from  embolic, 
thrombic,  or  other  processes. 

5.  Albuminuria  with  Disease  or  Disorder  of  Digestion. — 
This  category  includes  a  group  in  which  the  albuminuria 
could  only  be  referred  to  morbid  structural  or  functional 
changes  in  connection  with  the  digestive  process. 

6.  Nervous  Albuminuria. — A  group  of  cases  in  which 
the  albuminuria  appeared  to  be  related  to  changes  in  the 
nervous  system,  such  as  apoplexy,  epilepsy,  and  exophthal- 
mic goitre. 

7.  Albuminuria  with  Glycosuria. — This  group  includes 
cases  in  which  albuminuria  was  superadded  to  the  other 
chemical  abnormality  in  cases  of  true  diabetes  mellitus  or  of 
simple  glycosuria. 

8.  Functional  Albuminuria. — This  category  includes 
those  cases  in  which,  apart  from  any  evidence  of  organic 
change  in  the  kidney,  exercise  or  exertion,  diet,  exposure  to 


GENERAL    RESULTS. 


37 


cold,  mental  emotion,  or  obscure  cyclic  influences  account 
for  the  symptom. 

9.  Accidental  Albuminuria. — This  group  includes  the 
cases  in  which  albumen  is  added  to  the  urine  after  its 
secretion  by  the  kidney,  owing  to  admixture  with  blood,  pus. 
prostatic  or  seminal  fluid  during  its  course  through  the 
urinary  passages. 

10.  Probably  Accidental  Albuminuria. — This  category 
includes  cases  occurring  especially  in  women,  in  which  the 
presence  of  albumen  is  probably,  though  not  certainly, 
accidental. 

I  shall  ask  you  first  to  note  the  results  brought  out  in  the 
series  of  450  cases  of  disease  other  than  the  infectious  forms, 
which  do  not  often  present  themselves  in  a  physician's  con- 
sulting-room, and  are  not  admitted  to  the  Koyal  Infirmary 
or  the  Royal  Hospital  for  Sick  Children.  I  have  stated 
the  results  in  Table  XIII. 


Table  XIII. — Showing  Incidence  op  Albuminuria  in  450  Con- 
secutive Oases  Investigated  with  reference  to  the 
Probable  Causes. 


With  HN03. 

With  Picric  Acid. 

Total. 

1.  Bright's  Disease,  . 

43 

5 

48 

2.  Probably  Bright's  Disease, 

7 

2 

9 

3.  Febrile, 

6 

3 

9 

4.  Vascular, 

16 

7 

23 

5.  Alimentary,  . 

2 

8 

10 

6.  Nervous, 

1 

5 

6 

7.  With  Glycosuria,  . 

4 

2 

6 

8.  Functional,    . 

4 

2 

6 

9.  Accidental,    . 

9 

3 

12 

10.  Probably  Accidental, 

7 

0 

7 

99 

37 

136 

This  table  shows  that  of  our  450  cases,  136,  or  30 -2  per 
cent.,  showed  albuminuria.      Comparing  this  with  the  per- 


38  ALBUMINURIA. 

centage  of  our  series  of  505  presumably  healthy  individuals, 
we  find  that  in  that  series,  166,  or  32-8  per  cent.,  showed  the 
symptom.  But  when  we  look  at  the  proportion  of  cases 
showing  a  reaction  with  nitric  acid  or  picric  acid  respectively, 
we  find  that  the  difference  becomes  distinct,  for  while  among 
the  presumably  healthy  76  showed  with  nitric  and  90  with 
picric,  among  the  patients  99  showed  with  the  one  and  37 
with  the  other. 

It  is  thus  clear  that  the  slight  traces  are  proportionately 
more  common  among  the  presumably  healthy,  and  the  more 
distinct  reaction  among  the  sick. 

On  looking  over  the  different  categories  we  find  that 
Bright's  disease  accounts  for  more  than  one-third  of  all  the 
cases  of  albuminuria  met  with,  and  that  in  nearly  every 
instance  the  albumen  was  in  quantity  sufficient  to  be  made 
out  with  cold  nitric  acid.  Nine  cases  were  regarded  as 
probably  examples  of  Bright's  disease.  The  same  number  of 
cases  was  referred  to  the  category  of  febrile  albuminuria. 
That  only  1  in  14  of  the  cases  should  belong  to  this 
group  may  seem  at  first  sight  surprising,  but  it  is  to  be 
remembered,  on  the  one  hand,  that  fever  cases  are  not  ad- 
mitted to  the  Infirmary  or  the  Children's  Hospital,  and  very 
rarely  present  themselves  in  a  consulting-room,  and,  on  the 
other,  that  many  cases  of  febrile  albuminuria  afford  evid- 
ence of  some  structural  lesion  of  the  kidneys,  so  that  a  cate- 
gory, naturally  small  in  such  a  series  of  cases,  is  further 
reduced  by  the  number  included  in  other  groups.  The 
vascular  cases  amounted  to  nearly  1  in  6  of  the  series, 
thus  taking  the  second  place  in  frequency.  But  it  is  to  be 
observed  that  in  nearly  one-half  of  them  the  quantity  was  too 
small  to  be  shown  by  nitric  acid.  The  alimentary  cases  made 
up  1  in  13  of  the  series,  and  the  great  majority  showed 
only  the  faintest  trace  of  albumen. 

The  nervous  included  six  cases,  or  1  in  22|-  of  the  series, 


PRIVATE    PATIENTS. 


39 


and  except  in  a  single  case,  the  quantity  was  too  minute 
to  be  made  out  with  nitric  acid.  One  in  22|  were  also 
referred  to  the  category  of  albuminuria  with  glycosuria,  but 
the  larger  proportion  of  them  had  the  albumen  abundant. 
Six,  or  1  in  2  2  J,  were  regarded  as  examples  of  functional 
albuminuria,  and  in  them  also  two-thirds  showed  a  con- 
siderable quantity.  The  accidental  group  included  rather 
more  than  1  in  11,  and  of  them  also  two-thirds  had  the 
albumen  in  good  quantity.  Seven  cases  were  regarded  as 
probably  accidental  in  origin. 

I  shall  now  go  over  the  different  groups  individually. 

In  Table  XIV.  I  have  shown  the  results  obtained  in  the  series 
of  150  consecutive  private  patients,  giving  the  total  number 
of  cases  showing  albuminuria  with  the  total  number  which 
I  refer  to  each  category,  the  numbers  in  which  nitric  acid 
sufficed  to  demonstrate  the  symptom,  and  those  in  which  it 
only  became  apparent  on  the  addition  of  picric  acid. 


Table  XIY. — Showing  Incidence  of  Albuminuria  in  150  Con- 
secutive Private  Patients,  with  reference  to  the 
Probable  Causes. 


With  HN03. 

With  Picric  Acid. 

Total. 

1.  Blight's  Disease,    . 

12 

1 

13 

2.  Probably  Bright's  Disease,     . 

3.  Febrile 

0 
1 

0 
0 

0 
1 

4.  Vascular, 

1 

1 

2 

5.  Alimentary,    . 

6.  Nervous, 

1 
0 

2 
0 

3 
0 

7.  With  Glycosuria,   . 

8.  Functional,    . 

2 

4 

0 
2 

2 
6 

9.  Accidental,     . 

5 

3 

8 

10.  Probably  Accidental, 

1 

0 

1 

27 

9 

3(3 

In   this   series   the  preponderance    of   cases    of   Bright's 
disease  may  be  readily  understood,  when  one  considers  how 


40  ALBUMINURIA. 

often  the  subjects  of  these  maladies  are  able  to  go  about  and 
to  consult  physicians  in  their  own  houses.  The  second  group 
is  unrepresented,  because  in  every  instance  I  was  able  to 
arrive  at  a  definite  conclusion  as  to  the  existence  or  non- 
existence of  Bright's  disease.  The  third  or  febrile  group  is 
little  likely  to  appear  in  the  consulting-room.  Accordingly, 
only  one  instance  was  noticed.  The  vascular  group,  although 
so  common,  is  also  little  represented  in  consulting-room 
practice.  Cases  referable  to  the  fifth  group,  with  alimentary 
derangements,  were  rather  more  frequent — one  such  showing 
albumen  with  nitric,  two  with  picric  acid.  There  was  no 
case  belonging  to  the  nervous  group  in  this  series,  but  there 
were  two  with  glycosuria,  both  of  which  showed  albumen 
with  nitric  acid.  There  were  six  functional  cases,  four  show- 
ing it  with  nitric  acid  and  two  with  picric  ;  with  regard 
to  these,  some  particulars  are  desirable.  There  were  eight 
accidental  cases  and  one  probably  accidental,  six  of  them 
showing  with  nitric  acid  and  three  with  picric. 

The  first  of  the  functional  cases  which  showed  albumen 
with  nitric  acid  was  that  of  a  medical  man  in  active  practice, 
whose  urine  constantly  contained  a  considerable  amount  of 
albumen,  but  was  of  average  quantity  and  good  specific 
gravity,  and  contained  at  least  a  normal  amount  of  urea. 
There  were  none  of  the  other  symptoms  of  Bright's  disease 
present.  This  case,  therefore,  belongs  to  the  category  of  the 
simple  persistent  albuminurias.  The  second  case  was  that 
of  a  gentleman  with  slight  albuminuria,  who  was  much 
troubled  with  thirst,  and  who  passed  a  large  quantity  of  urine 
of  rather  low  specific  gravity,  but  the  urea  was  generally  dis- 
tinctly above  the  normal  amount.  There  were  no  other  signs 
of  Bright's  disease  present,  and  his  case  I  therefore  regard 
as  also  belonging  to  the  class  of  simple  persistent  albumin- 
uria. The  third  case  was  that  of  a  patient  who  had  slight 
constant  albuminuria,  with  a  normal  amount  of  urea,  and 


IN   INFIRMARY   PATIENTS. 


41 


who  was  otherwise  in  good  health.  I  am  inclined  to  place 
his  case  in  the  same  category  as  the  previous  two,  but  there 
is  also  a  possibility  of  the  albuminuria  having  been  accidental. 
The  fourth  case  was  that  of  a  delicate  girl,  with  no  marked 
signs  of  disease,  whose  urine  contained  a  small  quantity  of 
albumen.  This  case  probably  also  belongs  to  the  same 
category,  though  it  may  have  been  a  cyclic  one.  Regarding 
the  two  showing  albumen  only  with  picric  acid,  one  was  a 
case  of  intracranial  neuralgia,  and  the  other  a  case  simply  of 
overwork. 

In  Table  XV.  I  give  in  a  similar  way  the  results  obtained 
in  the  150  consecutive  indoor  Infirmary  patients. 

Table  XV. — Showing  Incidence  op  Albuminuria  in  150  Con- 
secutive Indoor  Infirmary  Patients,  with  reference  to 
the  Probable  Causes. 


1.  Bright's  Disease,    . 

2.  Probably  Bright's  Disease, 

3.  Febrile, 

4.  Vascular, 

5.  Alimentary,  . 

6.  Nervous, 

7.  With  Glycosuria,  . 

8.  Functional,   . 

9.  Accidental,   . 

10.  Probably  Accidental,     . 


With  HNO„  With  Picric  Acid.   Total 


22 
4 
3 

11 

1 

1 
2 
0 
4 
5 


53 


21 


26 
4 
5 

16 
6 
5 
3 
0 
4 
5 


74 


From  this  table  it  is  seen  that  26  of  the  74  cases  of 
albuminuria  met  with  in  the  wards  were  referred  to  Bright's 
disease  ;  2  2  of  them  showed  albumen  with  nitric  acid,  4  only 
with  picric  acid.  There  were  4  cases  which  gave  distinct 
reaction  with  nitric  acid,  and  were  probably  examples  of 
Bright's  disease.  There  were  5  febrile  cases,  3  showing 
albumen  with  nitric  acid,  and  the  other  2  with  picric  acid. 
Of  these,  3  were  cases  of  pneumonia,  and  2  articular 
rheumatism.     The  vascular  cases  were,  as  might  be  expected 


42 


ALBUMINUBIA. 


among  hospital  patients,  numerous,  amounting  to  16  of  the 
74,  and  of  them  11  showed  albumen  with  nitric  acid,  5  only 
with  picric  acid.  Those  connected  vath  gastric  disorder, 
such  as  dilatation  of  stomach  and  malignant  disease  of 
that  organ,  were  6  in  number,  1  showing  with  nitric  acid,  and 
5  only  with  picric  acid.  Cases  of  nervous  origin  were  5,  1 
showing  with  nitric,  and  4  with  picric  only  ;  2  of  the  5  were 
with  exophthalmic  goitre,  2  associated  with  epilepsy,  and  1  in 
a  case  of  multiple  sclerosis.  With  glycosuria,  albumen  was 
associated  in  3  cases,  2  showing  with  nitric  acid,  and  1  only 
with  picric.  Of  the  accidental  albuminurias  there  were  4,  all 
of  which  showed  with  nitric  acid.  The  probably  accidental 
were  5  in  number ;  4  of  these  cases  were  among  women, 
2  being  cases  of  gastric  ulcer,  1  a  case  of  dyspepsia,  and  1  a 
case  of  malignant  disease  of  the  stomach.  The  fifth  was  the 
case  of  a  man  with  a  functional  affection  of  the  spinal 
cord. 

The   next  group    is    the  outdoor   Infirmary  cases.     The 
results  are  stated  in  Table  XVI. 

Table  XYI. —  Showing  Incidence  of  Albuminuria  in  100 
Outdoor  Infirmary  Patients,  with  reference  to  the 
Probable  Causes. 


With  HN03. 

With 
Picric  Aeid. 

Total. 

1.  Bright's  Disease,       .... 

8 

0 

8 

2.  Probably  Bright's  Disease, 

3 

0 

3 

3.  Febrile,     .... 

0 

0 

0 

4.  Vascular,  . 

4 

1 

5 

5.  Alimentary, 

0 

1 

1 

6.  Nervous,  . 

0 

0 

0 

7.  With  Glycosuria, 

0 

1 

1 

8.  Functional, 

0 

0 

0 

9.  Accidental, 

0 

0 

0 

10.  Probably  Accidental, 

1 

0 

1 

16 

3 

19 

From  this  table  we  see  that  19  out  of  the  100  patients 
showed  albuminuria,  and  of  these  8  were  cases  of  Bright's 


IN    HOSPITAL   PATIENTS. 


43 


disease,  all  showing  with  nitric  acid  ;  3  were  regarded  as 
probably  Bright's  disease.  There  were  no  febrile  cases  ; 
5  were  referred  to  vascular  changes ;  4  showing  with 
nitric  and  1  with  picric  acid.  One,  which  was  so  slight  as 
to  be  shown  only  by  picric  acid,  was  referred  to  a  morbid 
state  of  the  alimentary  system.  There  was  no  nervous  case. 
One  was  associated  with  glycosuria ;  none  were  referable  to 
the  functional  or  the  accidental  groups,  and  there  was  only 
one  which  we  regarded  as  probably  accidental. 

In  Table  XVII.  is  shown  the  incidence  of  albuminuria 
among  50  patients  under  treatment  in  the  Sick  Children's 
Hospital. 


Table  XVII. — Showing  Incidence  of  Albuminuria  in  50  Sick 
Children,  Patients  in  the  Sick  Children's  Hospital,  with 
reference  to  the  probable  causes. 


With  HN03. 

With 
Picric  Acid. 

Total. 

1.  Bright's  Disease,       .... 

1 

0 

1 

2.  Probably  Bright's  Disease, 

0 

2 

2 

3.  Febrile,     .... 

2 

1 

3 

4.  Vascular, . 

0 

0 

0 

5.  Alimentary, 

0 

0 

0 

6.  Nervous,  . 

0 

1 

1 

7.  With  Glycosuria, 

0 

0 

0 

8.  Functional, 

0 

0 

0 

9.  Accidental, 

0 

0 

0 

10.  Probably  Accidental, 

0 

0 

0 

3 

4 

7 

There  was,  as  the  table  shows  only  one  case  of  Bright's 
disease.  Two  cases  in  which  picric  acid  showed  albumen 
were  regarded  as  being  probably  of  that  nature  ;  three  were 
febrile  ;  there  were  none  vascular  or  alimentary  ;  one  nervous, 
and  none  referable  to  the  other  categories. 

In  Table  XVIII.  are  shown  the  results  obtained  as  to  the 
occurrence  of  albuminuria  among  50  fever  patients  in  the 


44 


ALBUMINURIA. 


Edinburgh  Fever  Hospital.  I  first  give  trie  statistics 
of  the  whole,  and  then  the  statistics  as  to  scarlet  fever 
separately. 


Table  XVIII. — Showing  Incidence  of  Albuminuria  in  50 
Patients  in  the  Fever  Hospital,  with  the  Statistics  for 
Scarlet  Fever. 


Total  Number. 

With  HN03- 

With  Picric  Acid. 

Total. 

50 

18,  or  36  per  cent. 

15 

33,  or  66  per  cent. 

Statistics  for  Scarlet  Fever. 

With  HN03- 

With  Picric  Acid. 

Total. 

Scarlet  Fever  ) 
38            f 

13,  or  34*2  per  cent. 

10 

23,  or  60-53  per  ct. 

Of  the  50  cases,  18,  or  36  per  cent.,  showed  albumen  with 
nitric  acid,  and  33,  or  66  per  cent.,  showed  it  with  picric 
acid.  Taking  the  38  scarlet  fever  cases  separately,  we  find 
that  13,  or  34*2  per  cent.,  showed  albumen  with  nitric  acid, 
and  23,  or  60 "5 3  per  cent.,  with  picric  acid.  In  regard  to 
the  other  fevers,  the  observations  are  too  limited  in  number 
to  afford  any  percentage  results.  But  the  frequency  of  traces 
of  albumen  in  whooping-cough  was  noteworthy  :  of  6  cases, 
1  showing  it  largely  with  nitric  acid,  while  the  other  3  gave 
the  reaction  with  picric  acid.  The  strain  produced  by  the 
coughing  is,  I  believe,  an  important  factor  in  its  production. 
No  conclusions  can,  of  course,  be  drawn  from  the  few  cases  of 
typhoid  fever,  measles,  and  typhus  which  are  included. 

I  have  lastly  to  direct  your  attention  to  the  results 
obtained  in  40  cases  of  alcoholism,  either  acute  or  chronic, 
under  treatment  in  the  Royal  Infirmary.  The  specimens 
were  obtained  on  the  morning  after  their  admission  to  the 
wards.     These  results  I  have  put  in  Table  XIX. 


ALCOHOLISM.  4  5 


Table  XIX. — Showing  the  Incidence  op  Albuminuria  in  40 
Patients  suffering  from  Alcoholism,  either-  Acute  or 
Chronic,  under  Treatment  in  Ward  VI.,  Royal  Infirmary. 


Number. 

With  HN03. 

With  Picric  Acid. 

Total. 

40 

11,  or  27*5  per  cent. 

8 

19,  or  47"5  per  cent. 

One  would  naturally  expect  a  large  proportion  of  albu- 
minurias among  such  patients,  and  no  doubt  the  percentage 
is  high.  Still  we  must  remember  that  the  class  of  patients 
of  whom  this  group  is  composed  is  most  closely  related  to 
that  of  the  soldiers  ;  that  is,  the  conditions  of  life,  such  as 
severe  bodily  labour,  which  in  soldiers  conduce  to  make 
albuminuria  frequent,  are  also  in  operation  here.  Still,  the 
percentage  of  albuminurics  is  distinctly  higher  than  it  is 
amongst  the  soldiers,  and  indeed  more  closely  corresponds 
to  the  statistics  obtained  among  the  indoor  Infirmary  patients. 
While,  therefore,  the  albuminuria  is  probably  mainly  to  be 
ascribed  not  to  alcohol  but  to  the  conditions  of  life,  the 
alcohol  must  be  credited  with  the  increase  over  what  we 
would  expect  in  healthy  individuals  of  the  same  class.  This 
may  be  partly  a  direct  effect  of  the  alcohol,  but  doubtless  the 
indirect  influences  as  regards  inferior  diet,  and  bad  hygienic 
conditions  which  intemperance  and  improvidence  involve, 
are  also  factors  in  the  case. 

The  following  inferences  seem  to  be  warranted  from  the 
facts  that  I  have  collected  : — 

1.  That  as  in  health,  so  in  disease,  albuminuria  is  much 
more  common  than  is  generally  supposed. 

2.  That  it  is  more  common  among  patients  of  adult  age 
than  among  children. 

3.  That  cases  of  Bright's  disease  do  not  account  for  one- 
half  of  the  cases  of  albuminuria  met  with  in  practice. 


46  ALBUMINURIA. 

4.  That  they  account  for  more  than  any  other  individual 
cause. 

5.  That  next  to  them  rank  cases  induced  by  cardiac  and 
other  maladies  affecting  the  circulation,  and  those  due  to  the 
accidental  admixture  of  blood,  pus,  or  other  albuminous 
fluid  with  the  urine. 

6.  That  so  far  as  this  series  of  observations  shows,  the 
various  forms  of  functional  albuminuria  are  rare. 

7.  That  in  the  waxy  and  cirrhotic  diseases  of  the  kidneys, 
the  quantity  of  albumen  is  at  first  so  slight  as  to  be  shown 
only  by  picric  acid. 

8.  That  usually  in  these  when  advanced,  and  in  renal 
inflammation,  the  albumen  is  more  abundant  than  in  other 
varieties  of  albuminuria. 

9.  That  in  the  digestive  and  nervous  cases,  and  those  due 
to  high  temperature,  the  quantity  is  often  so  small  as  only 
to  be  discovered  by  picric  acid. 


We  now  turn  to  note  the  results  of  our  observations  as  to 
the  occurrence  of  peptones  in  the  series  of  cases  observed. 
In  Table  XX.  the  results  are  brought  out. 

Table  XX. — Showing  Incidence  of  Peptonuria  in  the 
Series  of  Cases  examined. 


Of  150  Private  Patients, 

4  gave 

the 

peptone  reaction 

150  Infirmary  Patients,     . 

16 

)! 

100  Outdoor  Infirmary  Patients, 

7 

)> 

50  Sick  Children,    . 

4 

)> 

50  Fever  Patients, 

3 

!> 

40  Alcoholic  Patients,     . 

1 

J> 

25  Puerperal  after  Delivery,  . 

2 

>! 

It  thus  appears  that  only  4  out  of  150  private  patients 
showed  this  condition.  These  cases  were,  first,  a  case  of 
cirrhotic  Bright's  disease,  with  gout  and  dyspepsia  ;  second, 
a  case  of  cirrhotic  Bright  with  heart  disease  ;  third,  a  case 
of   rupture    of   the    kidney  ;    and   fourth,    a   case    of   acute 


PEPTONURIA.  47 

rheumatism.  The  urine  also  contained,  in  each  of  the  cases, 
serum  albumen. 

Of  150  indoor  patients  at  the  Infirmary,  16  gave  the 
reaction.  These  were  a  case  of  dyspepsia,  a  case  of  malig- 
nant disease  of  the  liver,  stomach,  and  lungs;  a  case  of 
heart  disease,  two  of  phthisis  (one  of  them  syphilitic),  a 
case  of  pleurisy,  nine  cases  of  Bright' s  disease,  and  a  case 
of  acute  rheumatism.  Except  in  the  case  of  dyspepsia,  all 
the  urines  contained  serum  albumen  as  well. 

Of  100  outdoor  patients  examined  at  the  Infirmary,  seven 
showed  the  peptone  reaction.  They  were — a  case  of  phthisis 
with  waxy  disease  of  the  kidneys,  four  cases  of  Bright's 
disease,  one  of  hysteria,  and  one  of  syphilis.  The  urines 
all  contained  serum  albumen. 

Of  the  50  patients  examined  in  the  Royal  Hospital  for 
Sick  Children,  four  gave  the  reaction  for  peptones.  One  was 
a  case  of  meningitis  and  pneumonia  ;  another,  a  case  of 
infantile  paralysis  ;  the  third,  a  case  of  disease  of  the  spinal 
cord  ;  and  the  fourth,  a  case  in  which  the  diagnosis  was 
doubtful.  In  one  only  of  these  was  there  distinct  evidence 
of  serum  albumen. 

Of  the  50  fever  patients,  only  three  gave  the  reaction  ; 
and  among  the  forty  alcoholic  patients,  it  occurred  only 
once. 

Among  the  25  puerperal  cases  in  which  the  urines  were 
carefully  and  repeatedly  tested  after  delivery,  two  showed  a 
trace  of  peptone,  and  in  addition  there  were  six  cases  in 
which  it  was  doubtful  whether  a  trace  existed  or  not.  This 
result  differs  remarkably  from  that  obtained  by  Dr.  Fischel (31) 
in  the  course  of  his  researches  carried  out  in  the  wards  of 
Professor  Breisky  of  Prague  (now  of  Vienna).  He  examined 
the  urine  of  twenty-eight  pregnant  women,  and  found  peptone 
in  a  fourth  of  the  cases,  but  mostly  in  small  quantity,  so  far 
as  he  could  judge  by  the  intensity  of  the  red  coloration  in 


48  ALBUMINURIA. 

the  biuret  reaction,  but  it  was  not  constantly  present.  He 
examined  fifty-six  puerperal  patients  from  the  first  to  beyond 
the  twentieth  day,  making  one  hundred  and  fifty-one  testings. 
Among  them  he  found  eighty-six  showing  peptones  ;  fifty- 
eight  gave  a  negative  result.  Before  the  labour,  and  in 
the  first  twelve  hours  after  it,  peptones  never  appeared. 
In  the  second  half  of  the  first  day  usually  there  was  none, 
but  sometimes  a  trace.  In  the  second  and  third  days, 
peptonuria  was  almost  constant  (24  out  of  25  cases)  ;  on 
the  fourth,  fifth,  and  sixth  days,  it  was  very  frequent  (out  of 
44  testings  it  occurred  37  times).  From  the  seventh  to  the 
tenth  day,  half  the  cases  showed  it ;  after  the  tenth  day,  it 
was  very  rare. 

Such  discrepancy  necessarily  raises  the  question  whether 
the  method  of  testing  which  we  adopted  was  sufficient.  It  is 
certainly  the  best  plan  at  present  available  for  ordinary 
clinical  work,  the  methods  of  Schultzen,  Eiess,  Hofmeister, 
and  Kalfe (32)  being  far  too  elaborate  for  frequent  repetition. 
On  the  whole  we  seem  to  be  entitled  to  conclude  either  that 
peptones  are  not  so  common  as  Dr.  Fischel's  research  led 
him  to  believe,  or  that  if  he  is  correct,  the  quantity  is 
extremely  minute. 


LECTURE    IV. 

ON  THE  THEOEY  OF  ALBUMINURIA. 

Introduction. 

Albuminuria  may  be  ascribed  to  Changes  in  the  Blood. — Hydrosmia. — 

Inspissation. — Excess  of  Salts. — Deficiency  of  Salts. — Excess  of 

Albumen.- — Altered  Albumen. 
Altered  states  of  the  Filtering  Apparatus. 
Abnormal  Vascular  Tension. — Diminution  of  Tension. — Increase  of 

Tension. 
Changes  in  Epithelial  Cells  and  Stroma  of  Kidney. 
Conclusion. 

f^  ENTLEMEN,  —  Having  in  former  lectures  given  3^011 
the  results  of  our  inquiries  as  to  the  incidence  of 
albuminuria  in  presumably  healthy  people  and  in  various 
groups  of  patients,  I  shall  devote  the  present  meeting  to  an 
attempt  to  explain  what  we  at  present  know  as  to  the 
precise  mechanism  of  the  production  of  albuminuria. 

It  is  necessary  before  doing  so,  to  consider  the  process  of 
normal  urinary  secretion.  I  agree  with  those  who  think  that 
the  watery  part  of  the  urine,  along  with  certain  salts  held 
in  solution,  transudes  by  a  filtration  process  through  the  capil- 
laries of  the  Malpighian  tufts.  Whether  along  with  this  a 
certain  proportion  of  albumen  also  transudes  or  not,  as  experi- 
ments made  with  membranes  outside  the  body  would  lead  us 
to  expect,  is  not  with  certainty  ascertained.  Some,  for  whose 
opinion  I  have  much  respect,  believe  that  albumen  is  normally 
transuded  in  considerable  quantity  and  reabsorbed  by  the 
epithelium  lining  the  tubules,  but  the  arguments  and  experi- 
ments adduced  in   support  of  this  view  are  by  no  means  con- 

49  e 


50  ALBUMINURIA. 

elusive,  and  I  incline  to  think  that  the  blood  pressure  in  the 
capillary  loops,  and  the  walls  of  these  vessels,  with  their  thin 
epithelial  covering,  are  so  balanced  as  to  permit  of  the  transu- 
dation of  fluid,  and  yet  completely  or  almost  completely  to 
prevent  the  passage  of  the  albumen.  At  all  events,  we  may 
bold  with  certainty  that  the  water  is  mainly  eliminated  by 
nitration  through  these  structures.  But  the  urea  and  other 
urinary  solids  are  not  discharged  by  a  nitration  but  by  a  secre- 
tion process  performed  by  the  cells  of  the  tubules.  Along  with 
this  secretion,  as  in  the  case  of  other  glands,  a  certain  amount  of 
watery  fluid  passes,  and  the  capillaries  surrounding  the  tubules, 
of  course,  afford  the  material  from  which  the  secreting  struc- 
tures draw  their  supplies. 

It  is  certain  that  in  most  cases  the  transudation  of  albu- 
men takes  place  at  the  Malpighian  tufts.  Posner  pointed 
out  that  when  inflamed  kidneys  are  boiled,  coagulated  albumen 
is  found  occupying  the  cavity  of  the  capsule,  and  the  com- 
mencement of  the  tubules  ;  and  Ribbert (33)  showed  that  when 
albuminuria  had  been  induced  in  rabbits  by  temporary  clamp- 
ing of  the  renal  artery,  portions  of  the  kidney  hardened  in 
alcohol  exhibited  a  corresponding  condition.  Litten's^34)  ob- 
servations corroborated  these  results.  Confirmatory  evidence 
is  afforded  by  the  experiments  of  Nussbaum/35)  who,  taking 
advantage  of  the  fact  that  in  frogs  the  Malpighian  bodies  have 
an  arterial  supply  distinct  from  that  of  the  tubules,  obstructed 
the  supply  to  the  glomerular  arteries,  leaving  those  supplying 
the  tubules  free,  and  then  injected  egg  albumen  into  the 
blood,  with  the  result  that  no  albuminuria  followed,  as  would 
have  been  the  case  had  the  cortical  vessels  been  in  action. 

While  the  seat  of  transudation  of  albumen  is  thus  deter- 
mined, there  are  four  possible  ways  in  which  the  transudation 
might  arise.  It  might  be  due  to  faulty  conditions  of  the  blood  ; 
to  altered  states  of  the  filtering  apparatus — i.e.,  the  vascular 
walls  and   their   epithelial    coverings ;    to   abnormal   vascular 


CHANGES    IN    THE   BLOOD.  51 

tension  or  altered  circulation  ;  or  to  morbid  action  on  the  part 
of  the  epithelial  and  other  structures  of  the  kidney.  We  shall 
go  over  these  in  their  order,  and  indicate  the  share  which  each 
may  be  supposed  to  take  in  the  process.  Although  I  enumer- 
ate them  separately,  you  must  remember  that  this  is  warranted 
only  on  account  of  analysis,  for  the  individual  factors  rarely, 
if  ever,  act  alone. 

I. — Changes  in  the  Blood. 

That  the  discharge  of  albumen  in  Bright's  disease  is  not  due 
to  a  peculiarity  of  the  albumens  of  the  blood  was  shown  con- 
clusively by  Stokvis,(S6)  for  he  injected  albuminous  urine  into 
the  blood  of  animals,  and  found  that  no  albuminuria  resulted. 
Now,  had  the  albumen  escaped  from  the  kidneys  of  the 
patients  whose  urine  was  employed  in  the  experiments,  in  con- 
sequence of  a  peculiarity  of  the  substance  itself,  it  would  have 
again  escaped  from  the  kidneys  of  the  animals  into  whose  blood 
it  was  injected.  But  even  if  it  be  admitted  that  this  settles  the 
matter  as  regards  Bright's  disease,  it  throws  no  light  upon  other 
varieties  of  albuminuria,  and  there  has  been  so  much  theoreti- 
cal or  speculative  writing  upon  this  subject  that  it  deserves  care- 
ful consideration.  If  you  look  through  the  literature,  you  will 
find  that  the  following  possibilities  have  suggested  themselves  to 
different  minds.  Some  have  thought  of  undue  wateriness,  and 
some  of  undue  inspissation  of  blood;  some  of  excess,  and  some  of 
diminution  of  its  normal  salts ;  some  of  excess  of  one  or  other 
of  the  albumens  normally  present ;  and  some  of  the  develop- 
ment of  abnormal  and  more  diffusible  varieties  of  albumen. 

Now,  as  to  increased  wateriness  of  the  blood,  the  results  of 
various  experiments  by  Magendie,(37)  Mosler,(38)  and  others, 
seemed  to  show  that  dilution  of  the  blood  with  water  induces 
albuminuria.  This  appeared  to  support  the  view  maintained 
by  Owen  Rees,(39)  that  the  symptom,  when  it  occurs  in  the 
course  of  disease,  may   probably,  in   some   cases,    arise  from 


5  2  ALBUMINURIA. 

a  like  alteration.  But  the  experiments  of  Herrmann (40)  and 
Westphal  (41)  threw  doubt  upon  the  conclusions  of  their  pre- 
decessors, and  the  careful  researches  of  Stokvis,(36)  in  my  judg- 
ment, finally  set  the  theory  aside.  He  made  two  series  of 
experiments  on  the  lines  followed  by  Herrmann  and  Westphal, 
injecting  water  very  cautiously  in  small  quantities  at  a  time, 
a  precaution  which  had  been  neglected  by  the  earlier  observers, 
but  gradually  introducing  enough  greatly  to  dilute  the  blood. 
In  the  first  series,  which  included  six  experiments,  he  simply 
introduced  the  water  into  the  circulation  of  healthy  animals  ; 
in  the  second,  which  included  four,  he  first  bled  the  animals 
freely  in  proportion  to  their  size,  and  then  injected  the  water. 
In  none  of  the  first,  and  in  only  one  of  the  second  series 
did  albuminuria  result.  The  one  exceptional  case  threw  light 
upon  the  experiments  of  Magendie  and  others,  for  the  urine 
became  bloody,  and  I  cannot  resist  the  conclusion  that  the 
occurrence  of  hsematuria  as  well  as  albuminuria  in  the  earlier 
experiments  proved  that  rupture  of  renal  vessels  had  occurred, 
so  that  the  process  could  not  be  truly  reckoned  a  hsemato- 
genous  albuminuria,  nor  the  experiments  a  proof  of  the  view 
that  they  were  supposed  to  justify. 

The  opposite  condition  of  undue  inspissation  of  the  blood 
may  be  suggested  as  a  possible  explanation  of  some  cases  of 
albuminuria,  for  it  sometimes  occurs  in  the  course  of  diseases 
attended  by  profuse  watery  discharges,  such  as  violent 
diarrhoea  and  cholera,  in  which  the  water  of  the  blood  must 
be  considerably  reduced,  the  proportion  of  albumen  is  increased. 
But  when  we  look  closely  into  the  facts  as  to  the  incidence 
of  albuminuria  in  cholera  the  suggestion  finds  little  support 
so  far  as  it  is  concerned.  The  albuminuria  of  cholera  is 
most  marked  in  the  stage  of  reaction,  and  follows  upon 
the  anuria  of  the  period  of  collapse.  Now,  the  period  of 
collapse  is  that  in  which  there  must  be  the  greatest  inspis- 
sation   of   the   blood.      The    inspissation    has   already   begun 


CHANGES    IN    THE    BLOOD.  53 

to  diminish  when  the  stage  of  reaction  sets  in,  and,  as  it  is 
then  that  the  albuminuria  appears,  we  must  conclude  that 
inspissation  is  not  the  cause.  It  has  been  asserted  that  during 
the  collapse  stage  albuminuria  is  absent  only  because  there 
is  little  or  no  urinary  secretion,  and  that  if  a  few  drops  can 
be  obtained  with  the  catheter  or  otherwise,  it  is  albuminous. 
But,  granting  this,  it  does  not  follow  that  inspissation  of 
blood  is  the  cause,  and,  by  combining  the  results  of  ana- 
tomical investigation  with  those  of  certain  experiments,  we 
arrive  at  a  much  more  satisfactory  explanation.  The  condi- 
tion of  the  kidneys  is  found  to  correspond  anatomically  to 
what  is  seen  as  a  result  of  temporary  ligature  of  the  renal 
arteries — viz.,  changes  in  the  Malpighian  tufts,  and,  taking 
together  these  facts  and  the  sequence  of  symptoms,  I  agree 
with  Bartels^42)  in  thinking  that  the  altered  blood  supply,  and 
the  changes  consecutive  to  it,  afford  us  the  best  explanation 
of  the  phenomena  of  the  disease.  Making  allowance  for  this 
and  for  the  fact  that  more  extensive  inflammatory  changes  are 
often  set  up,  we  find  a  sufficient  explanation  of  albuminuria 
in  cases  of  cholera,  and,  on  the  whole,  you  will  find  that  the 
blood-inspissation  hypothesis  rests  upon  no  sufficient  foundation. 
There  is  more  to  be  said  in  favour  of  the  view  that  excess 
of  salts  in  the  blood  may  induce  albuminuria.  Experiments 
by  Hoppe-Seyler (43)  and  others  have  shown  that  when  the 
salts  in  an  albuminous  solution  are  increased,  the  albumen 
transudes  more  readily  through  animal  membrane,  and  there 
is  every  reason  to  believe  that  this  holds  good  in  the  case 
of  the  blood — that  when  its  salts  are  in  excess  its  albumen 
may  more  readily  pass  through  the  vascular  walls.  Urea  itself 
has  been  found  to  exert  the  same  influence  as  the  salts ;  and 
it  is  possible  that  in  some  instances  albuminuria  is  in  this 
way  produced,  or  at  least  that  its  occurrence  is  favoured. 
But  of  this  I  know  no  definite  evidence  except  that  afforded 
by  Lupine's (4^  experiments  upon  dogs,  in  which  he  found  that 


54  ALBUMINURIA. 

temporary  albuminuria  resulted  from  the  intravenous  injection 
of  chloride  of  sodium  in  the  proportion  of  1  gramme  to  each 
kilogram  of  the  animal's  weight.  Notwithstanding  the 
interest  of  this  result  it  seems  unlikely  that  the  increase  of 
salts  can  in  any  instance  be  an  important  clinical  factor. 

The  opposite  view,  according  to  which  albuminuria  is 
supposed  to  result  from  deficiency  of  salts,  and  especially 
of  chloride  of  sodium,  has  been  ably  dealt  with  by  Professor 
Stokvis,(36)  who  tells  how  Wundt,(45)  having  experimented  upon 
himself  by  using  saltless  food  for  a  number  of  days,  induced 
albuminuria ;  his  results  being  confirmed  by  experiments 
which  Rosenthal (46)  performed  on  animals.  Stokvis  made  two 
series  of  experiments  on  himself — abstaining  from  the  use 
of  salt  on  one  occasion  for  five  days,  and  on  another  for 
seven ;  but  although  the  urine  was  changed  in  various 
important  respects,  it  never  showed  a  trace  of  albumen.  He 
experimented  also  upon  the  dog  and  the  rabbit,  feeding  the 
animals  in  various  ways,  but  without  or  with  very  little  salt, 
with  results  entirely  confirming  the  experiments  made  upon 
himself.  I  am  not  aware  that  deficiency  of  other  salts  has 
been  blamed.      This  view  must  also  be  rejected. 

As  to  the  idea  of  excess  of  one  or  other  of  the  normal 
albumens  of  the  blood,  there  are  two  which  might  be  increased, 
namely,  —  serum-albumen,  and  serum-globulin.  Estelle (47* 
and  Faveret,(48)  working  under  the  direction  of  Ldpine,  found 
that  when  they  injected  watery  solutions  of  serum-albumen 
and  globulin  into  the  veins  of  animals,  albuminuria  resulted, 
the  variety  excreted  corresponding  to  that  introduced.  Now, 
it  is  very  natural  to  suppose  that  during  digestion,  when  the 
proportion  of  albumen  in  the  blood  must  be  greater  than  at 
other  times,  the  excess  of  it  may  in  part  transude  through 
the  renal  vessels ;  and  when  we  consider  how  often  some 
trace  of  albumen  appears  after  meals,  and  how  frequently  a 
copious  dieting  with  eggs  induces  the  condition,  it  is  difficult 


CHANGES    IN    THE    BLOOD.  55 

to  resist  the  conclusion  that  in  some  cases  this  must  be  a 
cause  of  albuminuria.  Still,  there  are  difficulties  in  the  way 
of  accepting  this  as  the  full  explanation  of  such  albuminurias  ; 
for  the  most  albuminous  meals  do  not  seem  to  be  the  most 
apt  to  produce  the  symptom.  An  ordinary  breakfast  cannot 
be  held  to  be  as  albuminous  as  an  ordinary  dinner  ;  and  yet 
it  seems  to  be  after  breakfast  rather  than  after  dinner  that 
the  condition  is  apt  to  occur  ;  and  if  the  explanation  were 
to  be  found  here,  albuminuria  after  food  ought,  one  would 
think,  to  be  even  more  common  than  it  is. 

As  to  the  development  of  abnormal  forms  of  albumen  within 
the  blood — forms  more  capable  of  transudation  than  serum- 
albumen  and  globulin — we  have  extremely  little  evidence. 

Professor  Semmola(49)  of  Naples  is  at  the  present  day  the 
most  ardent  advocate  of  this  explanation  of  albuminuria. 
Indeed,  he  is  of  opinion  that  the  organic  lesions  of  Bright's 
disease  are  secondary  results  of  irritation  of  kidneys,  due 
to  the  discharge  of  an  abnormally  diffusible  albumen,  which 
he  supposes  to  be  present  in  the  blood.  But  the  arguments 
and  observations  which  he  adduces  in  support  of  his  view  are 
far  from  convincing.  And,  indeed,  one  feels  that  the  suggested 
explanation  is  still  simply  hypothetical. 

The  results  elicited  by  Stokvis  in  two  of  his  injection  expe- 
riments are  certainly  suggestive  in  this  connection.  He  found 
that  in  these  two  instances,  and  in  them  alone  out  of  twenty- 
three,  albumen  appeared  in  the  urine  of  the  animals  operated 
upon,  and  in  both  cases  the  urine  used  for  injection  had  been 
taken  from  a  patient  suffering  from  albuminuria  without  defi- 
nite renal  disease.  It  seems  probable  that  the  case  may  have 
been  one  of  functional  albuminuria,  and  that  an  easily  diffus- 
ible form  of  albumen  existed  in  the  urine. 

The  appearance  of  peptones  in  the  urine  cannot,  of  course, 
be  explained  by  anything  occurring  in  the  renal  secreting 
structures  or  the  urinary  tracts.      They  must,  whatever  their 


56  ALBUMINURIA. 

origin,  be  derived  from  the  blood.     They  are  not  usually  given 
in  works  on  physiological  chemistry  as  normal  constituents  of 
the  blood;   indeed,  the  researches  of  Ott  and  Collmar(50)  point 
to  the  conclusion  that  they  act  as  poisons,  producing  fever. 
But  we  are  fully  warranted  in  concluding  that  they  are  some- 
times present.     Otherwise  how  could  their  presence  in  the  urine 
be  explained  ?     They  filter  more  readily  through  animal  mem- 
branes than  serum-albumen  or  globulin,  and,  when  introduced 
into  the  circulation,  are  passed  out  by  the  kidneys,  and  the  pre- 
sence of  an  excess  of  this  variety  of  albumen  in  the  blood  may 
therefore  be  recognised  as  a  cause  of  albuminuria.    Egg-albumen 
also,  when  introduced  into  the  blood,  or  injected  subcutaneously, 
passes  out  as  such  with  the  urine  ;  but  seeing  that  in  the  artifi- 
cial albuminuria  induced  by  the  ingestion  of  large  quantities  of 
uncooked  white  of  egg,  it  is  not  egg-albumen  which  transudes 
but    serum-albumen,    we    must    conclude     that    this    variety 
practically  never  occurs  in  the  human  subject.      Experiments 
have  further  shown  that  the  injection  of  milk  or  of  solutions 
of  casein  into  the  blood  of  living  animals  is  usually  followed 
by  discharge  of  casein  or  other  albuminous  substance  with  the 
urine,    but   the   use  of  milk   and   cheese   as   articles  of  diet 
does   not,  unless   as   a   result   of  idiosyncracy,  produce   albu- 
minuria.     As  to  the  idea  of  other  forms  of  albumen  resulting 
either  from   transformation   of  the  normal  albumens   of  the 
serum,  or  of  the  albumen  of  the  corpuscles,  we  have,  so  far  as 
I  know,  no  definite  knowledge  at  present.      There  are  some 
facts  which  favour  the  opinion  that  changes  in  the  corpuscles 
may  induce    it.      Dr.   Ralfe (51)  has  worked    out,    with    great 
ability  and   elaboration,  a  view  which    I    have   been  in  the 
habit     of    teaching,     that     a    form     of    albuminuria    stands 
closely    related    to    hemoglobinuria.       He    has    shown    what 
we   may  call  three  stages   in    the  process   of   abnormal   dis- 
integration   of   red   blood    corpuscles    within    the    liver — the 
first  marked  by  increase  of   urea,  the    second    by   that   and 


CHANGES   IN    THE    BLOOD.  57 

albuminuria,  the  third  by  the  further  addition  of  hemo- 
globinuria. The  mere  albuminuria  in  these  cases  might 
be  ascribed  to  the  action  of  an  irritant  upon  the  kidney 
tissue,  but  the  hemoglobinuria  is  not  susceptible  of  such  an 
explanation,  and  if  it  is  not,  the  other  also  may  not  be  so 
explained.  Here,  then,  it  may  be  that  we  have  an  altered 
albumen  transuding  more  readily,  but  further  investigation 
would  be  required  to  bring  out  fully  the  chemical  differences 
between  it  and  ordinary  blood-albumens.  Rosenbach/52) 
working  somewhat  in  the  same  lines  as  Ralfe,  had  come  to 
the  conclusion  that  probably  in  certain  morbid  conditions  the 
albumens  of  the  blood  are  set  free  from  their  normally  close 
combination,  and  so  are  readily  eliminated.  This  explanation 
is  also,  in  the  meantime,  purely  hypothetical,  so  far  as  the 
blood  is  concerned.  And,  even  if  it  were  proved,  the  question 
would  remain  for  discussion,  Why  the  kidneys  should  permit 
of  its  elimination  ? 

Lupine' s^  ingenious  suggestion  that  the  albumen  may  be 
chemically  combined  with  foreign  substances  introduced  into  the 
blood,  and  may  in  such  combination  act  as  an  irritant  to  the 
kidney  and  thereby  produce  albuminuria,  is  also,  as  yet,  hypo- 
thetical. 

Globulin  transudes  more  easily  than  serum-albumen  ;  and 
Dr.  Maguire(54)  has  found  that  in  some  cases  of  functional 
albuminuria  there  was  relatively  more  of  globulin  than  of 
serum-albumen,  and  he  even  met  with  globulin  alone.  In 
a  case  of  purpura  which  many  of  you  will  remember  as 
having  been  recently  in  my  wards,  and  in  which  albumen 
was  abundantly  present  in  the  urine,  globulin  was  present  in 
larger  quantity  than  the  serum-albumen ;  and  it  is  possible 
that,  had  that  case  been  entirely  free  from  renal  inflammation, 
there  might  have  been  no  serum-albumen  at  all,  but  simply 
the  globulin.  In  that  patient  I  believe  disintegration  of  red 
corpuscles  was  going  on  far  in  excess  of  the  normal.     It  may 


58  ALBUMINURIA. 

turn  out  that,  not  only  in  purpura,  but  in  scorbutus,  in  per- 
nicious anaemia,  and  in  simple  anaemia,  albuminuria  may  be 
partly  due  to  this  cause ;  and  I  have  no  doubt  that  careful 
clinical  and  chemical  work  in  this  direction  would  be  abundantly 
rewarded. 

In  connection  with  the  injection  of  egg  albumen  the  very 
interesting  and  suggestive  fact  has  been  elicited  by  some  of 
the  experiments,  that  a  greater  quantity  of  albumen  is  passed 
out  by  the  kidneys  than  had  been  injected  into  the  blood. 
This  points  either  to  changes  set  up  in  the  blood  by  the 
presence  of  the  egg  albumen,  or  to  irritation  and  structural 
changes  in  the  kidneys  themselves. 

I  would  have  you  then  conclude  that,  while  the  albuminuria 
of  Bright's  disease  is  not  of  hematogenous  origin,  there  is  some 
reason  to  believe  that  certain  other  varieties  may  arise  from 
changes  in  the  blood,  perhaps  from  excess  of  salts,  or  from  excess 
of  albumen,  or  from  the  presence  of  abnormal  forms  of  albumen. 

II. — Altered  States  of  the  Filtering  Apparatus. 

When  we  consider  such  a  process  as  that  of  secretion  of 
urine,  it  is  obvious  that  it  must  be  greatly  influenced  by 
the  character  of  the  membrane  through  which  the  filtration 
occurs  ;  and  it  is  natural  to  suppose  that  altered  conditions  of 
the  filtering  apparatus  may  sometimes  determine  albuminuria. 

This  apparatus  is  composed,  as  we  have  seen,  of  the  loops 
of  vessels  in  the  Malpighian  tufts,  with  their  covering  of  flat- 
tened epithelium,  and  it  is  conceivable  that  transudation  of 
albumen  might  result  either  from  changes  in  the  vessel  walls 
or  in  the  epithelium,  or  in  both.  The  change  in  the  vessel 
wall,  with  which  we  are  most  familiar,  is  the  waxy  or  amyloid 
degeneration  ;  and  in  the  earliest  paper  which  I  wrote  upon 
Waxy  Kidney,(55)I  suggested,  as  a  hypothetical  explanation,  at 
once  of  the  polyuria  and  albuminuria,  which  are  characteristic 
of  that  disease,  an  abnormal  permeability  of  the  vessel  walls. 


ALTERED    STATES    OF    THE    FILTERING   APPARATUS.  oV 

This  view  has  been  very  generally  accepted  as  probable,  but 
no  positive  proof  of  its  correctness  has  been  forthcoming,  and 
it  must  stand  as  a  suggestion  rather  than  as  a  demonstrated 
fact.  But  Ribbert(33)  has  found  that  in  cases  of  the  kind  there 
is,  in  addition  to  the  vascular  change,  a  distinct  alteration  in 
the  cellular  elements  of  the  Malpighian  bodies — in  fact,  a 
glomerulonephritis.  He  says,  that  in  slightly  affected  glo- 
meruli, where  only  individual  loops  were  diseased,  he  found 
the  albumen  within  the  capsules,  and  undeniable  changes  in 
the  epithelium,  which  clearly  indicated  a  slight  degree  of 
glomerulo-nephritis.  In  one  case,  fatal  at  an  early  stage, 
which  I  lately  examined,  there  certainly  were  changes  of  this 
kind  superadded  to  the  slight  vascular  alteration,  and  it  may 
be  that  to  this  secondary,  rather  than  to  the  primary  change, 
the  albuminuria  must  be  referred.  In  either  case,  however, 
the  starting-point  is  in  the  vessels. 

In  all  the  ordinary  cases  of  glomerulo-nephritis,  such  as  we 
see  typically  after  scarlet  fever,  the  filtering  apparatus  is  mani- 
festly at  fault,  and  the  researches  of  Ribbert  point  to  the  con- 
clusion that,  under  a  great  variety  of  conditions,  similar  changes 
arise  in  the  nutrition  of  the  vessel-walls  and  their  epithelial 
covering.  The  vessels,  being  nourished  by  the  blood  which 
passes  through  them,  suffer  whenever  that  blood  is  faulty  in 
character  or  deficiently  supplied.  When  it  is  loaded  with 
such  substances  as  phosphorus  or  carbolic  acid,  he  finds  that 
characteristic  changes  occur  in  the  Malpighian  bodies.  So  also 
when  the  renal  arteries  are  clamped  for  a  short  time — say,  for 
a  quarter-of-an-hour — slight  changes  occur ;  if  the  experiment 
be  continued  for  half-an-hour,  the  results  are  much  more  pro- 
nounced. Similar  failure  of  nutrition  has  been  shown  to  follow 
hindered  outflow  of  blood  in  consequence  of  venous  stasis,  or 
of  urine  from  obstruction  of  ureter,  and  to  occur  after  serious 
haemorrhages,  after  cholera,  in  severe  anaemia,  and  in  advanced 
carcinoma ;  and  perhaps  in  such  blood  diseases  as  purpura  and 


60  ALBUMINURIA. 

scorbutus,  there  is  a  corresponding  alteration  of  the  filtering 
apparatus. 

It  is  obvious  that  the  causes  which  induce  changes  in  what 
we  have  termed  the  filtering  apparatus  proper,  cannot  be 
limited  in  their  operation  to  these  structures,  but  must  often 
affect  the  epithelium  of  the  tubules  generally,  and  the  inter- 
stitial tissue  of  the  kidneys  as  well,  so  that  uncomplicated 
alterations  of  the  filtering  apparatus  must  be  of  the  very 
rarest  occurrence.  For  example,  the  effect  of  urinary  stasis, 
while  it  induces  changes  in  the  glomeruli,  has  been  shown  by 
Aufrecht/56)  in  his  admirable  work  on  diffuse  nephritis,  to 
extend  to  the  epithelium  of  the  tubules  and  other  structures 
of  the  organ.  We  thus  find  these  alterations  of  the  filtering 
apparatus  linked  on  to  more  extensive  changes,  which  we 
shall  consider  somewhat  later  in  the  lecture. 

I  would  have  you,  then,  believe  that  albuminuria  in  waxy 
disease  of  the  kidney,  probably  owes  its  origin  to  increased 
permeability  of  the  vessel  wall,  or  to  this  in  association  with 
changes  in  the  glomerular  epithelium,  and  that  alterations  of 
the  filtering  apparatus  are  to  be  recognised  as  the  cause  of 
albuminuria  in  some  forms  of  poisoning,  in  fevers,  and  in 
many  altered  conditions  of  the  renal  circulation. 

III. — Abnormal  Vascular  Tension  and  Altered 
Circulation. 
The  vascular  arrangements  connected  with  the  Malpighian 
bodies  differ  from  those  of  any  other  part  of  the  economy  in 
respect  that  they  are  composed  of  capillary  loops  covered  with 
a  layer  of  very  delicate  epithelium,  and  are  guarded  both  at 
their  entrance  and  their  exit  by  arteries  capable  of  regulating 
the  current  of  blood  flowing  through  them.  Tension  in  the 
capillaries  may  thus  be  increased  by  relaxation  of  the  afferent 
or  by  contraction  of  the  efferent  vessels,  or  diminished  by  spasm 
of  the  former  and  relaxation  of  the  latter. 


ABNORMAL    VASCULAR   TENSION.  61 

The  two  opposite  conditions  of  increased  and  diminished 
tension  have  been  suggested  as  possible  explanations  of  albu- 
minuria. The  latter  attracted  a  good  deal  of  notice  when 
it  was  first  propounded  by  Professor  Runeberg  of  Helsingfors.(57) 
He  thought  that  when  the  vascular  tension  was  diminished, 
transudation  of  albumen  was  apt  to  occur,  founding  chiefly 
upon  experiments  made  by  filtration  through  dead  animal 
membranes  under  various  degrees  of  pressure.  It  was  clear 
enough  that  albuminuria  often  made  its  appearance  when 
the  blood  pressure  in  the  kidneys  was  diminished,  as,  for 
example,  in  many  varieties  of  anaemia,  and  after  clamping 
of  renal  arteries.  Herrmann (58)  and  Yon  Overbeck,(59)  had 
ascertained  that  when  the  renal  artery  was  temporarily 
constricted,  the  urine  secreted  at  the  time  was  scanty  and 
albuminous.  And  Francois (60)  has  shown  that  the  albumen 
in  these  conditions  transudes  through  the  Malpighian  bodies. 
It  is  clear  that  anatomical  changes  in  the  filter  arise  in 
many  of  these  cases,  and  it  is  not  improbable  that  the 
albuminuria  is  due  to  these  changes  rather  than  directly 
to  the  diminished  supply  of  blood.  But  that  diminution  of 
tension  is  not  the  great  cause  of  albuminuria  has  been 
conclusively  shown  by  Senator, (20)  Litten,(61)  and  others.  I  am 
not  sure,  however,  that  the  views  which  Runeberg  intended  to 
express  have  always  been  correctly  understood.  I  have, 
along  with  Dr.  Stevens,  made  a  number  of  experiments 
bearing  on  the  filtering  process.  We  found  that  an  albu- 
minous and  saline  solution  placed  so  that  it  might  filter 
through  a  membrane,  transuded  with  increase  of  pressure  a 
much  larger  proportion  of  the  water  and  the  salts  within 
a  given  time,  but  that  the  amount  of  albumen  was  also 
increased,  although  not  in  the  same  proportion.  We  found 
moreover  that  when  the  experiments  were  prolonged,  the 
membrane  became  so  altered  that  transudation  after  a 
time  diminished  and  ultimately  ceased,   and  it  appears  pro- 


62  ALBUMINURIA. 

bable  that  fallacies  due   to   this  fact   have   not   always   been 
avoided. 

Recognising  the  fact  that  increase  of  pressure  leads  to 
increase  of  transudation  through  membranes,  outside  of  the 
body,  how  does  it  stand  in  relation  to  the  process  within  the 
kidneys  of  living  animals  ? 

It  is  reasonable  to  suppose  that  increased  vascular  tension 
exists  in  the  renal  veins,  and  possibly  also  in  the  Malpighian 
tufts  in  cases  in  which  the  outflow  of  blood  from  the  kidneys  is 
hindered.       That  albuminuria  results  from  venous  stasis  has 
been    proved   experimentally  by  many,  among  whom   I   shall 
name  Dr.  Robinson (61)  of  Newcastle,  and  it  is  a  matter  of  every- 
day  clinical   observation.       The   stasis   occurs   mainly  in   the 
vessels  surrounding  the  uriniferous  tubules,  and  Senator (20)  has 
demonstrated  that  it  is  from  these  vessels  that  the  transuda- 
tion of  albumen  first  takes  place.      He  found  that  if  he  liga- 
tured the  renal  veins  of  animals,  and  killed  them  in  from  eight 
to  fifteen  minutes  afterwards,  an  albuminous  exudation  was 
distinct  in  the  tubes  and  not  in  the  Malpighian  bodies,  and 
that  if  he  continued  the  experiment  for  a  longer  time,  exuda- 
tion occurred  in  the  glomeruli  also.      In  cases  of  cardiac  or 
other  disease   hindering  the  outflow  of  the  venous  blood,  the 
albuminuria  may  be  ascribed  primarily  to  the  vessels  surround- 
ing the  tubules,  but  also  to  the  Malpighian  bodies.     Although 
in  these  cases  increase  of  pressure  within  the  vessels  may  be 
held  to  exist,  it  does  not  follow  that  it  causes  the  albuminuria. 
It  may  be  maintained  that  the  real  cause  is  a  slowing  of  the 
circulation,  as  has  been  suggested  by  such  high  authorities  as 
Litten,(34)  Posner,(62)  Heidenhain,(63)  Bamberger,(64)  and    Char- 
cot/65) but  I  have  not  been  able  to  satisfy  myself  of  the  weight 
of  the  evidence  which  they  adduce  in  support  of  this  opinion. 
It  may  also  be  maintained  that  nutritive  changes  occur  in  the 
epithelium  which  favour  transudation.     But,  on  the  whole,  and 
especially  in  consideration  of  Senator's(20)  observations,  I  am 


ABNORMAL    VASCULAR    TENSION.  63 

inclined  to  ascribe  the  transudations  to  increased  intravascular 
tension. 

It  is  very  doubtful  whether  increased  pressure  in  the 
arterial  system  or  within  the  Malpighian  bodies  is  capable  of 
producing  albuminuria.  Attempts  have  been  made  to  increase 
the  blood  pressure  in  the  renal  vessels  by  tying  the  aorta 
below  the  point  of  origin  of  the  renal  arteries,  by  this  and 
tying  other  vessels,  also  by  cutting  out  one  kidney,  but  it  is 
more  than  doubtful  whether  the  blood  pressure  is  really  raised 
by  such  proceedings.  The  results  as  to  albuminuria  have  also 
been  inconstant.  Attempts  have  been  made  to  ascertain 
whether  the  increase  of  pressure  within  the  aorta  produced 
by  electrical  irritation  of  the  cervical  portion  of  the  spinal 
cord,  and  by  the  administration  of  such  poisons  as  strychnia 
and  digitalis  induces  albuminuria.  The  results  show  that  if 
albumen  is  transuded,  it  is  not  at  the  time  that  the  aortic 
tension  is  greatest,  but  afterwards ;  the  explanation  being  that 
the  aortic  tension  is  due  to  spasm  of  the  small  arteries,  and 
it  is  only  when  this  spasm  has  relaxed,  and  the  circulation 
become  re-established,  that  the  symptom  occurs.  One  diffi- 
culty which  attends  this  inquiry  arises  from  the  fact  that 
the  tension  in  the  Malpighian  bodies  does  not  necessarily 
correspond  to  that  in  other  vessels. 

Clinical  evidence  also  lends  little  support  to  the  opinion 
that  increased  pressure  within  the  Malpighian  tufts  induces 
albuminuria.  In  diabetes  insipidus  there  must  be  increased 
blood  pressure,  and  yet  albuminuria  is  a  rare  accompaniment 
of  this  disease.  Many  of  you  have  watched  the  case  at 
present  under  treatment  in  the  Alexandra  Ward,  and 
have  noted  that  the  urine  has  sometimes  amounted  to  600 
ounces  in  the  twenty-four  hours,  but  you  remember  that  the 
most  delicate  tests  failed  to  give  positive  evidence  of  albumen. 
Such  observations  necessarily  throw  a  shade  of  doubt  over  the 
occurrence   of   albuminuria  simply   from  increase    of   tension 


64  ALBUMINURIA. 

within  the  Malpighian  tufts.  Again,  if  one  watches  the 
action  of  digitalis  and  similar  diuretics,  one  notices  that  so  far 
from  the  quantity  of  albumen  increasing  as  the  diuretic  action 
is  brought  out,  it  actually  diminishes  or  entirely  disappears, 
and  yet  the  diuresis  can  only  be  explained  on  the  hypothesis 
of  increased  blood  pressure.  There  must  also  be  a  marked 
increase  of  pressure  within  the  Malpighian  tufts  in  many  cases 
of  renal  cirrhosis,  when  the  urine  is  excessive,  and  yet  in  such 
cases  the  amount  of  albumen  is  often  trifling. 

There  are,  however,  some  conditions  in  which  increased  tension 
may  be  reasonably  held  to  be  at  least  associated  with  albuminuria. 
Muscular  exertion  is  one  of  these.  With  such  exertion  the 
tension  necessarily  rises,  and  we  have  seen  how  often  severe 
muscular  exertion  suffices  to  produce  albuminuria, — as  among 
the  soldiers  on  fatigue  duty  and  the  boys  at  football.  I  know 
of  no  explanation  of  these  facts  more  satisfactory  than  the 
hypothesis  that  the  increase  of  pressure  suffices  to  produce  it. 
We  have  also  seen  that  in  the  course  of  fever  albuminuria 
often  occurs,  the  arterial  tension  being  sometimes  simultane- 
ously increased ;  and  experiment  has  shown  that  animals 
exposed  to  high  temperature  often  exhibit  the  symptoms.  It 
may  be  that  the  increased  tension  is  one  factor  in  its  produc- 
tion. But  at  the  best  this  could  only  be  regarded  as  one  of 
several  influences  in  operation. 

Another  group  of  cases  which  might  with  considerable 
probability  be  referred  to  alterations  of  vascular  tension  is 
that  including  albuminuria  from  changes  in  the  nervous 
system. 

The  influence  of  that  system  upon  the  kidney,  and  especi- 
ally upon  its  circulation,  has  been  the  subject  of  many 
experiments,  and  it  may  be  well  to  indicate  some  of  the 
anatomical  and  physiological  points  which  have  been  ascer- 
tained. Although  the  capsule  and  the  pelvis  of  the  organ 
are    sensitive,  the    substance    does   not    seem    to    be  largely 


ABNORMAL    VASCULAR    TENSION.  65 

supplied  with  sensory  nerves.  Neither  do  we  know  anything 
of  nerves  which  influence  the  actual  secretory  processes  per- 
formed by  the  cells.  But  as  to  the  influence  of  the  nervous 
system  on  the  circulation,  a  good  deal  has  been  made  out. 

The  vasomotor  nerves  run  from  the  cortical  substance  of 
the  brain  through  the  crura  to  a  centre  in  the  medulla 
oblongata.  Fibres  reach  the  same  centre  from  the  cerebellum. 
From  the  medulla  fibres  pass  downwards  along  the  lateral 
column  of  the  cord  and  pass  out  along  with  the  anterior  nerve 
roots,  receiving  fibres  from  independent  vasomotor  centres  in 
the  anterior  horns.  They  pass  out  between  the  seventh 
cervical  and  the  twelfth  dorsal  and  enter  the  sympathetic,  and 
form  the  sixth,  ninth,  and  tenth  thoracic  ganglia.  Thence 
they  make  their  way  through  the  splanchnic,  cceliac,  and 
renal  plexuses  to  the  vessels  of  the  kidney.  Their  irritation 
contracts  the  vessels,  producing  pallor  and  slowness  of  circula- 
tion and  secretion.  Their  paralysis  dilates  them  ;  in  conse- 
quence, the  kidneys  swell,  circulation  quickens,  and  secretion 
increases. 

Irritative  and  paralytic  results  may  be  experimentally  pro- 
duced at  any  point  in  the  course  of  the  fibres. 

It  appears  also  from  Roy's (66)  experiments  that  there  are 
nerve  structures  within  the  kidneys  which  influence  the 
vessels,  for  changes  may  be  produced  in  them  by  passing 
currents  of  certain  salts  through  kidneys  whose  nervous  supply 
has  been  cut  off. 

That  it  is  possible  for  albuminuria  to  be  produced  by  the 
influence  of  the  nervous  system  is  shown  by  its  appearance 
after  apoplexy,  epilepsy,  and  hysteria,  as  well  as  its  experi- 
mental production  by  puncture  of  a  point  in  the  floor  of  the 
fourth  ventricle.  These  conditions  may  result  from  vascular 
dilatation  directly  produced,  or  as  a  secondary  result  of  spasm, 
or  perhaps  from  impairment  of  nutrition  of  the  filtering 
apparatus  in  the  Malpighian  bodies.      But  oar  present  know- 


C  6  ALBUMINURIA. 

ledge  does  not  warrant  our  expressing  a  positive  opinion  as  to 
what  the  precise  connection  is.  Certainly  we  have  no  definite 
proof  of  its  being  due  to  increased  intravascular  tension. 

I  would  have  you  then  believe  that  albuminuria  may  result 
from  increased  pressure  within  the  vessels  of  the  kidney,  both 
in  cases  of  cardiac  and  pulmonary  disease,  which  have  led  to 
hindrance  of  circulation,  and  under  other  conditions,  but  that 
neither  increase  nor  diminution  of  intravascular  tension  is  an 
important  direct  cause  of  albuminuria. 

IV. — Morbid  Action  of  the  Epithelial  Cells  of  the 
Tubules  and  of  other  Structures  of  the  Kidney. 

It  is  difficult  to  give  absolute  proof  of  the  influence  exerted 
by  structural  changes  in  the  kidney  elements  proper,  because 
it  may  be  maintained  that  although  they  are  distinct  enough 
in  themselves,  they  produce  albuminuria  only  by  altering  the 
circulation,  or  otherwise  modifying  the  conditions  of  secre- 
tion. But  when  we  consider  how  everywhere  throughout 
the  body  transudation  of  albumen  takes  place  in  connec- 
tion with  the  inflammatory  process,  we  perceive  how  this  must 
occur  in  the  kidney  also.  Indeed,  it  is  obvious  that  this 
feature  of  inflammation  should  be  conspicuous  among  the 
symptoms  of  disease  in  such  an  organ  as  the  kidney. 

In  the  severest  inflammatory  changes  such  as  we  see  in 
acute  renal  atrophy,  often  associated  with  acute  atrophy 
of  the  liver,  in  phosphorus  poisoning,  in  the  sudden  inflam- 
mations which  occasionally  supervene  in  the  course  of  diabetes 
mellitus,  and  with  tumours  of  the  kidney,  the  amount  of 
albumen  is  very  great.  Its  quantity  varies  in  those  less 
rapid  inflammations  which  follow  scarlet  fever  and  other  acute 
maladies.  It  is  still  less  abundant  where  the  process  is  more 
chronic  in  character  or  limited  in  extent ;  but,  the  rule  is,  that 
wherever  inflammatory  action  in  the  kidneys  exists,  albumin- 


MORBID    ACTION    OF    THE    EPITHELIAL    CELLS,    ETC.  07 

uria  is  distinct.  In  long  standing  cases  of  chronic  inflamma- 
tion, the  albumen  may  be  discovered  at  every  examination 
through  many  years. 

Admitting,  as  every  one  does,  the  association  of  these  clinical 
and  anatomical  conditions,  two  lines  of  explanation  have  been 
suggested.  On  the  one  hand,  it  is  maintained  that  while  the 
urine  is  in  the  healthy  condition  secreted  free  from  albumen, 
in  the  course  of  inflammatory  action  albuminous  materials  are 
copiously  drawn  from  the  blood,  and  discharged  along  with 
the  secretion.  On  the  other,  it  is  suggested  that  whereas  in 
health  the  watery  part  of  the  blood  which  filters  through  the 
Malpighian  tufts  is  accompanied  by  albumen,  and  only  gets 
free  of  it  by  the  absorbing  power  of  healthy  renal  epithelium, 
so  that  by  the  time  it  reaches  the  lower  parts  of  the  tubular 
system  it  has  become  a  practically  non-albuminous  fluid ;  in 
inflammation,  the  epithelium  losing  this  power,  the  albumen 
passes  freely  down  along  with  the  watery  secretion.  But 
even  the  most  strenuous  supporters  of  this  view  seem  to 
admit  that  in  inflammation  of  the  tubules  inflammatory 
exudation  must  account  for  some  of  the  albumen.  On  the 
whole,  it  appears  to  me  most  reasonable  to  accept  the  first 
view  in  its  entirety  as  the  most  satisfactory  explanation  both 
of  the  acute  and  chronic  inflammatory  albuminuria. 

To  sum  up  the  results,  then,  I  would  have  you  believe 
that  albuminuria  is  very  often  due  to  changes  of  an  inflam- 
matory character  in  the  epithelium  of  the  tubules  and  in  the 
stroma  of  the  organ,  and  that  in  a  very  large  proportion  of  the 
cases  in  which  it  occurs  in  practice  it  is  dependent  upon  this 
cause  ;  that  increased  blood  pressure  is  a  factor  of  some  import- 
ance ;  that  increased  permeability  of  the  filtering  apparatus 
induces  it  in  many  instances  ;  and  that  there  may  be  some 
conditions  of  the  blood  which  account  for  it  or  favour  its 
occurrence. 


LECTURE    V. 

ON  ALBUMINURIA  FROM  INFLAMMATION  OF  THE 
KIDNEYS. 

Synonyms. — Case  of  Acute  Inflammation  with  Urcemia. —  Varieties 
of  Features  with  same  Lesion. —  Very  Chronic  Case. — Non- 
Infective  Chronic  Case. — Case  with  Pericarditis. — Explanation 
of  the  Albuminuria. 

C\  ENTLEMEN, — I  purpose  now  to  go  over  the  different 
categories  which  have  emerged  in  our  study  of  the 
incidence  of  albuminuria,  and  I  shall  begin  with  the  best- 
known  and  simplest  forms,  those  in  which  organic  change  of 
kidney  is  the  cause,  leaving  over,  meanwhile,  the  consideration 
of  the  obscurer  groups,  such  as  the  albuminuria  induced 
among  healthy  people  by  diet  or  exercise.  Our  first  category 
embraces  various  forms  of  renal  lesion  which  we  are  accus- 
tomed still  to  rank  as  Bright' s  disease.  It  includes  in  our 
series  of  450  patients  (400  under  my  own  care,  and  50 
in  the  Children's  Hospital),  48  cases  in  all.  Of  these, 
16  were  inflammatory,  11  cirrhotic,  14  waxy,  and  7  mixed. 
To-day  I  shall  bring  before  you  a  series  of  cases  illustrating 
the  variety  of  renal  lesion  which  has  been  termed  inflamma- 
tory Bright's  disease,  parenchymatous  nephritis,  tubular 
nephritis,  or  desquamative  nephritis.  I  shall  first  show 
you  a  patient  who  was  not  treated  in  the  Infirmary,  but 
whom  I  saw  in  private,  and  who  has  to-day  come  that 
you    may   judge    of    his    condition.       He    is    a    school-boy, 

twelve  years  of  age.      He  lately  passed  through  an  attack  of 
68 


ACUTE    INFLAMMATION    WITH   UREMIA.  69 

scarlet  fever.  The  fever  was  never  severe,  and  desquamation 
went  on  satisfactorily.  During  its  continuance  he  was  kept 
perhaps  less  strictly  to  milky  food  than  one  could  have  wished, 
and  unfortunately  was  exposed  one  day  to  a  draught  of  cold  air. 
The  next  morning  he  had  become  seriously  ill,  his  face  pale 
and  pasty,  his  eyelids  swollen,  dropsy  rapidly  developing  in 
hands  and  feet,  and  throughout  the  body  generally.  His  urine 
was  scanty  in  amount,  of  dark  colour,  of  high  specific  gravity, 
highly  albuminous,  depositing  urates  on  standing,  and  the 
microscope  showed  it  to  be  loaded  with  blood  corpuscles 
and  with  epithelial,  hyaline,  granular,  and  bloody  casts. 
The  utmost  care  was  taken,  and  suitable  remedies  employed, 
but  the  condition  steadily  became  worse,  and  towards  the 
evening  of  the  second  or  third  day  of  the  illness  nervous 
twitchings  of  muscles  manifested  themselves,  and  during 
the  night  ursemic  convulsions  and  coma  set  in.  I  was 
asked  to  see  him  in  the  early  morning,  and  immediately 
injected  a  sixth  of  a  grain  of  pilocarpin  subcutaneously, 
applied  hot  bottles  all  round  the  body,  and  put  on  extra 
bed-clothes.  Under  this  treatment,  very  copious  diaphoresis 
was  established,  and  the  uraemia  began  to  subside.  The 
action  of  the  skin  was  kept  up,  while  the  bowels  were  freely 
relieved  by  a  hydragogue  cathartic,  and  the  kidneys  acted 
upon  by  digitalis.  The  quantity  and  quality  of  the  urine 
speedily  improved,  and  the  symptoms  subsided,  so  that,  as  you 
see,  the  patient  now  presents  a  healthy  appearance,  and  the 
urine,  which  is  in  good  quantity,  shows  no  albumen  with  the 
nitric  acid  test. 

This  is  a  good  typical  instance  of  the  infective  form  of  this 
malady.  It  is  not  necessary  for  me  to  describe  minutely  the 
appearance  which  the  kidneys  would  have  presented  had 
they  been  examined  during  the  anxious  days  of  the  acute 
attack.  Your  experience  enables  you  to  depict  this  accur- 
ately in  your  own  minds.      Rather   above  the    natural    size, 


70  ALBUMINURIA. 

the  capsule  stripping  off  readily,  the  surface  generally  con- 
gested, and  probably  marked  here  and  there  by  minute  haem- 
orrhages, they  would  have  shown  on  section  the  cortical  sub- 
stance swollen,  with  general  congestion,  scattered  haemorrhages, 
and  an  altered  condition  of  the  tubules,  perceptible  even  with 
the  naked  eye.  Microscopical  examination  would  have  revealed 
an  opaque  condition  of  many  tubules,  due  to  swelling  and 
rapid  inflammatory  destruction  of  epithelium,  and  in  some 
parts  extravasation  of  blood,  while  the  glomeruli  and  stroma 
would  almost  certainly  have  shown  more  or  less  of  the  inflam- 
matory changes  characteristic  of  glomerular  and  interstitial 
nephritis.  But  now  all  that  is  happily  changed ; — if  we  were 
to  examine  his  kidneys  to-day,  we  should  find  them  practi- 
cally normal ;  perhaps  here  and  there  a  tubule  may  still  show 
traces  of  the  recent  inflammation,  perhaps  at  some  points  the 
glomeruli  or  interstitial  tissues  might  still  show  alterations, 
but  these,  if  they  exist,  will  I  hope  pass  away  and  leave  no 
trace  behind. 

You  have  seen  in  the  wards  other  cases  of  this  kind  which 
never  showed  the  same  dangerous  symptoms,  and  you  will 
find,  as  you  gather  experience  in  practice,  that  the  varieties 
of  feature  presented  by  these  cases  is  very  extraordinary.  You 
may  sometimes  see  the  urine  almost  black,  and  scarcely  any 
dropsy  present ;  at  others,  the  dropsy  may  be  so  severe,  serous 
effusion  being  added  to  the  general  anasarca,  that  death  is 
threatened  from  obstruction  to  respiration  and  circulation. 
You  may  see  the  illness  so  slight  that  it  is  never  formidable, 
and  passes  away  in  a  few  days,  or  you  may  see  it  prove  fatal 
in  a  few  hours,  or  you  may  see  it  set  up  chronic  changes  in 
the  kidney  which,  after  persisting  for  years,  at  last  terminate 
fatally.  I  lately  met  a  remarkable  instance  of  this  kind  of 
case  in  a  lady  about  forty-three  or  forty-four  years  of  age, 
whom  I  knew  well,  having  frequently  seen  one  of  her  relatives 
during   a  very  formidable    illness   through  which   he   passed. 


FROM   CHRONIC    INFLAMMATION.  71 

She  looked  healthy,  was  active,  full  of  animation,  and  worked 
night  and  day  during  the  anxious  months  of  her  friend's 
illness.  But  she  used  casually  to  say,  "  You  know  that  I  have 
got  albuminuria,  and  have  had  it  for  many  years."  About  a 
year  later  she  came  to  see  me,  looking  very  different  from  her 
former  self.  She  was  pale  and  breathless,  and  her  feet  and 
legs  were  swollen,  and  on  going  into  her  case,  a  full  discus- 
sion of  which  she  had  previously  wished  to  avoid,  I  elicited 
this  history.  She  had  been  quite  healthy  as  a  child,  but  at 
eight  or  ten  had  scarlet  fever.  This  was  followed  by  nephritis 
apparently  of  a  very  serious  type,  but  in  the  end  she  recovered 
to  a  great  extent,  and  when  she  grew  up  showed  no  bad 
symptom  except  persistent  albuminuria.  She  went  on  living 
like  other  people,  and  mixing  in  all  the  most  fashionable  life 
in  London,  till  her  marriage,  at  the  age  of  two-and-twenty. 
She  was  an  accomplished  horsewoman,  and  rode  regularly  to 
the  hounds.  She  had  no  bad  symptom  at  the  birth  of  any 
of  her  six  or  seven  children,  and  I  believe  showed  rarely  any  - 
thing  to  attract  attention  beyond  the  albuminuria,  which  was 
carefully  watched  by  the  very  skilful  practitioner  who  was  her 
ordinary  attendant.  The  arterial  tension  by  the  time  she  con- 
sulted me  had  become  distinctly  increased.  The  heart  was 
hypertrophied  and  dilated,  and  the  mitral  valve  incompetent. 
She  had  recently  suffered  a  good  deal  from  gout,  and  from 
the  symptoms  of  cardiac  dilatation  and  valvular  insufficiency. 
She  gradually  lost  ground,  and  ultimately  died  of  a  combina- 
tion of  dropsy  with  uraemia.  There  was  no  opportunity  of 
making  a  post-mortem  examination,  but  the  facts  which  I 
have  given  afford  satisfactory  proof  that  the  post-scarlatinal 
nephritis  had  initiated  chronic  inflammatory  action,  which 
went  on  for  more  than  thirty  years,  and  at  last  terminated 
fatally.  In  her  case  you  will  observe  that  there  must  have 
been  at  first  extensive  disease  of  the  tubules,  with  affection  of 
the  glomeruli  and  stroma,  that  the  tubules  recovered  to  a  great 


72  ALBUMINURIA. 

extent,  but  all  the  while  insidious  changes  were  going  on  in 
the  stroma,  so  that  the  organs  underwent  a  very  gradual  atrophy. 
Changes  were  set  up,  and  secondary  complications  at  length 
ensued,  which  the  system,  enfeebled  by  fatigue  and  gout, 
proved  unable  to  resist. 

Besides  such  infective  forms  of  renal  inflammation  there  are 
non-infective  varieties  which  present  a  history  very  similar  to 
the  above,  except  in  respect  of  their  etiology.  I  shall  draw 
your  attention  to  one  case  illustrative  of  certain  points  which 
I  deem  important,  and  which  I  watched  with  great  care  a 
number  of  years  ago.  When  he  came  under  my  care,  R.  P. 
was  a  man  of  twenty-six,  and  till  January,  1865,  had  been 
quite  healthy.  His  trade  had  been  that  of  a  baker,  and  later 
he  was  a  maltster,  and  in  this,  as  in  his  former  occupation,  he 
was  often  exposed  to  vicissitudes  of  heat  and  cold.  He  was 
admitted  to  the  Infirmary  on  the  3rd  of  March,  suffering  from 
severe  dropsy  and  ursemic  convulsions.  Under  treatment,  by 
means  of  cupping  over  the  kidneys  and  diuretics,  he  improved 
to  some  extent,  but  again  relapsed,  and  while  the  head  symp- 
toms did  not  reappear  the  dropsy  became  very  pronounced. 
Diuretics  of  various  kinds,  including  digitalis  and  acid  tartrate 
of  potash,  were  tried  without  good  result,  but  diuresis  was 
established  by  the  inhalation  of  oil  of  juniper,  a  remedy  which 
you  will  sometimes  find  useful  where  other  diuretics  fail. 
Punctures  were  made  in  the  skin  of  the  legs  with  the  view  of 
draining  off  the  dropsical  fluid,  and  very  good  results  followed. 
When  the  dropsy  disappeared,  the  urine  continued  in  fair 
quantity,  the  albumen  became  less,  the  casts  much  fewer,  and 
the  urea  reached  its  normal  standard.  He  was  dismissed  from 
the  Infirmary  five  months  after  his  illness  began,  in  all  respects 
well,  except  that  his  urine  was  albuminous.  You  will  often 
see  cases  with  histories  more  or  less  closely  corresponding  to 
this.  I  wish  that  we  had  it  in  our  power  either  by  diet  or  by 
medicine  to  check  the  lingering  inflammation  which  is  still 


FROM   (JHRONIC    INFLAMMATION.  73 

going  on  and  really  get  the  patient  restored.  Having  left 
the  Infirmary,  he  was  necessarily  exposed  to  cold,  wet,  and 
changes  of  temperature.  Soon  he  got  worse,  and  in  three 
months  returned  with  a  renewal  of  all  his  bad  symptoms. 
The  urine  was  again  diminished,  the  dropsy  considerable,  and 
ursemic  convulsions  recurred.  Under  treatment  with  diuretics 
he  again  improved,  and  was  dismissed  for  the  second  time,  nine 
months  after  the  commencement  of  his  illness.  A  few  months 
later  he  came  to  the  hospital,  said  he  felt  quite  well,  and  there 
was  really  nothing  to  be  detected  wrong  with  him  except 
that  his  urine  contained  some  albumen.  In  March,  1871,  he 
returned,  stating  that  he  had  again  caught  cold,  and  that 
although  during  the  intervening  years  he  had  been  able  for 
his  work,  he  never  had  been  quite  strong.  His  urine  had 
been  up  to  the  normal  amount,  but  he  had  had  occasion  to 
rise  once  or  twice  every  night  in  order  to  micturate.  His 
heart  was  found  to  be  enlarged,  its  muscular  substance  weak, 
the  second  sound  was  accentuated  in  the  aortic  area,  and  the 
first  was  muffled  and  rather  indistinct.  His  vessels  were 
thickened.  His  urine  amounted  to  ninety  ounces  daily, 
was  highly  albuminous,  and  contained  hyaline  and  granular 
casts.  He  occasionally  suffered  from  headache,  but  there 
were  no  eye  changes,  and  no  tendency  to  fits.  In  June 
of  the  same  year  he  returned  in  a  feebler  condition,  but 
again  rallied.  From  time  to  time  he  came  into  the 
Infirmary,  gradually  deteriorating  in  health,  and  with  occa- 
sional returns  of  dropsy.  At  length,  after  his  illness  had 
lasted  for  eight  years,  his  age  then  being  thirty-four,  he  looked 
like  a  man  of  at  least  fifty.  His  face  was  pale  and  rather 
pinched,  his  general  health  was  very  poor,  every  system  being 
more  or  less  unsound.  With  feeble  digestion,  impoverished 
and  impure  blood,  diseased  heart  and  vessels,  embarrassed 
respiration,  a  tendency  to  dropsy,  deficiency  of  solids  in  urine, 
and  disordered  nervous   system,   he   gradually  became   worse 


74  ALBUMINURIA. 

and  worse,  and  ultimately  died  of  uraemia.  His  kidneys 
were  found  somewhat  atrophied,  granular,  and  uneven  on 
the  surface.  The  capsule  tore  off  with  some  difficulty.  There 
was  a  distinct  relative,  probably  even  an  absolute  increase  of 
fibrous  stroma,  but  the  most  interesting  histological  point 
was  the  blocking  of  many  of  the  tubules  with  inflammatory 
products,  the  tubules  presenting  a  great  variety  of  shape, 
some  of  them  altogether  obliterated.  It  was  evident  that 
the  diminution  of  bulk  of  the  organ  was  not  mainly  due, 
as  in  cirrhosis  of  the  kidney,  to  a  shrinking  of  the  fibrous 
tissue,  but  in  part  at  least,  if  not  chiefly,  to  the  molecular 
absorption  of  the  contents  of  the  tubules,  in  the  way  that 
I  have  tried  to  explain  in  my  work  on  Bright's  Disease/67* 

It  is  not  necessary  to  bring  before  you  other  individual 
instances  of  a  condition  which  you  see  so  frequently  in  the 
wards.  It  may  suffice  if  I  recall  one  example  which  must  have 
impressed  itself  deeply  on  the  minds  of  many  of  you.  You 
remember  the  case  of  the  young  man  who  had  for  about  seven 
months  suffered  from  inflammatory  Bright's  disease,  who  had 
persistent  dropsy,  copious  albuminuria,  hypertrophy  of  heart, 
and  extraordinary  increase  of  arterial  tension.  You  remember 
how  that  patient  one  day  at  our  visit  was  observed  to  have  an 
altered  appearance,  with  marked  depression.  His  face  was  pale, 
the  tension  of  the  pulse  was  gone,  the  action  of  the  heart  had 
become  feeble ;  he  had  a  good  deal  of  pain  in  the  precordia  and 
epigastrium,  and  many  of  the  members  of  the  class  had  the 
opportunity  of  hearing  the  intense  friction  when  they  listened 
over  the  heart.  In  that  patient  pericarditis  had  set  in, 
and  it  proved  rapidly  fatal. 

In  the  course  of  chronic  cases  symptoms  and  complications 
arise  which  are  often  more  immediately  dangerous  than  the 
disease  itself.  I  do  not  enter  upon  their  consideration  at 
present,  as  I  intend  to  discuss  them  in  future  lectures,  after 
I  have  made  you  familiar  with  the  general  features  of  other 


CAUSE    OF   ALBUMINURIA    IN"    INFLAMMATION.  75 

forms  of  renal  disease.  Neither  shall  I  at  the  present  time 
go  into  the  subject  of  treatment.  You  have  seen  what  line 
was  followed  in  each  of  the  cases  adduced,  and  other  oppor- 
tunities will  present  themselves  of  discussing  it  at  length. 

The  question  remains  as  to  the  cause  of  the  albuminuria 
in  these  cases.  It  seems  to  me  that  there  can  be  no 
reasonable  doubt  that  it  is  due  from  first  to  last  to  the  in- 
flammatory action — that  the  inflammation,  whether  acute  or 
chronic,  leads  to  the  transudation  of  serum  from  the  blood, 
and  so  to  albuminuria.  No  doubt  the  breaking  down  of  the 
epithelial  structures  contributes  to  this  in  some  measure,  but 
that  measure  is  small  when  compared  with  the  exudation 
element. 


LECTURE    VI. 

ALBUMINURIA  FROM  CIRRHOSIS  OF  THE  KIDNEYS. 

Synonyms. — General  Features. — Case  of  fully  Developed  Disease. — 
Case  in  Early  Stage. — Renal  Inadequacy. — Explanations  of 
the  Albuminuria. 

C\  ENTLEMEN, — I  shall  show  you  to-day  some  cases  illus- 
trative of  one  of  the  most  important  causes  of  albu- 
minuria— cirrhosis  of  kidney,  a  condition  often  spoken  of  as 
contracting  kidney  and  gouty  kidney,  sometimes  as  rough 
granular  kidney. 

The  first  glance  at  this  patient  suggests  the  probability 
that  he  is  suffering  from  chronic  Bright's  disease.  You 
observe  the  peculiar  pallor  of  his  face,  the  fulness  of  the 
lower  eyelids,  the  localised  sparkle  of  his  eyes,  due  to 
oedema  of  the  conjunctivae,  the  somewhat  blank  expression 
so  common  in  those  who  do  not  see  well,  the  prominence 
and  tortuosity  of  the  temporal  arteries,  and  when  you  put 
your  finger  upon  his  radial  artery,  it  feels  like  a  cord  or 
tendon  rather  than  a  normal  vessel.  Such  a  group  of 
symptoms  suggests  at  once  to  any  one  familiar  with  the 
disease,  that  the  patient  is  the  subject  of  renal  cirrhosis. 

But  while  such  an  appearance  may  be  said  to  be  patho- 
gnomonic of  this  condition,  it  is  by  no  means  constant. 
For  you  often  see  men,  and  still  more  frequently  women, 
who  have  long   suffered  from  the  malady,   whose   general 

appearance    presents    nothing    to    attract    attention.      And 
76 


RENAL    CIRRHOSIS.  77 

again,  you  may  see  a  vascular  congestion,  or  a  muddiness 
or  dirtiness  of  skin,  or  a  general  duskiness  with  congestion 
over  the  nose  and  cheeks,  contrasting  remarkably  with  what 
I  show  you  in  the  present  patient. 

The  great  outstanding  features  of  this  disease  are,  so  far 
as  the  urine  is  concerned,  the  normal  or  somewhat  excessive 
quantity,  the  pale  colour  and  low  specific  gravity,  the  pre- 
sence of  albumen  in  moderate  amount,  the  deficiency  of 
urea  and  the  paucity  of  tube  casts  ;  and,  so  far  as  concerns 
general  symptoms,  the  consequent  changes  in  the  digestive, 
circulatory,  respiratory,  and  nervous  systems. 

This  patient,  J.  S.,  a  joiner,  is  in  his  twenty-sixth  year, 
an  earlier  age  than  is  common  in  the  disease.  Still  as 
you  gain  experience  you  will  often  enough  see  it  in  young 
people.  It  is  most  common  in  its  fully  developed  form 
between  the  ages  of  40  and  55,  and  in  lesser  degree  it  is 
common  at  a  more  advanced  age.  I  have  often  met  with 
it  in  adolescents  and  sometimes  even  in  children. 

He  came  from  Sunderland,  seeking  advice  as  to  headache, 
and  dimness  of  sight,  having  suffered  from  the  former  for  two 
years,  from  the  latter  for  eight  months.  Patients  affected 
with  renal  cirrhosis  rarely  come  to  you  complaining  of  their 
kidneys.  It  is  after  a  convulsive  attack,  or  on  account  of 
palpitation,  or  breathlessness,  or  dyspepsia,  or,  as  in  this 
instance,  for  headache  and  dimness  of  sight,  that  they  are  led 
to  seek  advice  ;  and  these  symptoms  do  not  arise  until  the 
disease  has  existed  for  a  long  time,  even  as  long  as  from  five 
to  eight  years.  There  is  no  difficulty  in  diagnosing  the  con- 
dition at  this  stage  ;  it  is  much  more  difficult  to  make  it 
out  in  the  earlier  part  of  its  course. 

His  parents  are  healthy,  and,  so  far  as  I  could  discover, 
there  was  no  case  of  Bright's  disease  among  his  relatives. 
Now  and  then  we  find  a  different  history.  Sometimes  one, 
sometimes  many  relatives  have  died  of  the  disease.     I  have 


78  ALBUMINUKIA. 

met  with  at  least  one  family  in  which  its  prevalence  and 
fatality  were  terrible,  and  several  in  which  it  was  recognised 
as  a  family  complaint. 

He  never  drank  to  excess.  Indulgence  in  alcohol  is  a 
well-known  cause  of  the  malady,  and  that  not  only  in  those 
who  indulge  in  drinking  bouts,  but  also  in  those  who  habit- 
ually drink  too  much,  although  they  do  not  become  quite 
intoxicated.  Among  my  cases  in  young  people  there  has,  as 
a  rule,  been  no  alcoholic  taint. 

It  is  possible  that  another  cause  may  have  been  in  opera- 
tion— viz.,  lead-poisoning.  As  a  ship-carpenter  he  may  very 
probably  have  been  in  contact  with  paints  containing  lead, 
but  of  this  we  have  no  proof.  You  remember  the  case  of 
the  house-painter,  at  present  under  treatment  on  account  of 
renal  cirrhosis,  in  whom  lead-poisoning  was  undoubtedly  one 
of  the  chief  causes  ;  and  in  not  a  few  of  your  cirrhotic  cases 
you  will  find  that  the  same  influence  is  at  work. 

He  had  scarlet  fever  at  eight,  followed  by  otorrhosa, 
but  neither  by  dropsy  nor  other  renal  symptoms,  and  he 
says  that  he  considered  himself  a  quite  healthy  man  till 
about  a  year  ago.  We  may  therefore  conclude  that  his 
renal  disease  is  not  a  sequence  of  the  fever. 

The  headache  at  first  used  to  last  a  day,  gradually  it 
became  more  persistent,  and  was  attended  by  noises  in  the 
ears.  Eight  months  ago  he  began  to  have  difficulty  in 
reading,  and  soon  became  unable  to  read  ordinary  news- 
paper type.  The  right  eye  was  worse  than  the  left.  He 
suffered  also  a  good  deal  from  pain  in  the  small  of  the  back. 

For  three  years  our  patient  acted  as  carpenter  on  board 
ship.  He  often  passed  through  the  Red  Sea,  and  he  noticed 
that  his  headaches  were  worse  there.  We  can  well  under- 
stand how  with  the  stress  of  his  work  as  ship-carpenter, 
the  climate  of  the  Red  Sea  should  have  induced  head- 
aches,   or   contributed   to   their    production,  but  they  were 


RENAL    CIRRHOSIS.  79 

doubtless  mainly  referable  to  the  insidiously  advancing  renal 
disease. 

When  we  come  to  examine  his  condition  according  to  our 
usual  method,  we  find  in  the  alimentary  system  that  his 
tongue  is  flabby  and  somewhat  furred.  He  frequently 
complains  of  dyspeptic  symptoms,  such  as  pain  after  food, 
heartburn,  flatulence,  and  vomiting,  and  he  suffers  from 
constipation.  The  liver  is  of  normal  size.  Some  enlarged 
glands  are  felt  at  the  back  of  the  neck,  but  the  spleen  and 
other  blood  glands  are  normal.  The  red  corpuscles  vary  from 
3,040,000  to  3,690,000,  the  haemoglobin  from  40  to  48  per 
cent.  There  is  some  dyspnoea  on  exertion,  but  the  heart 
shows  no  marked  increase  in  size,  and  there  is  no  cardiac 
murmur.  The  first  sound  in  the  mitral  area  is  impure, 
and  has  somewhat  of  the  booming  character  which  one 
expects  in  this  disease ;  while  in  the  aortic  area  the  second 
sound  is  distinctly  accentuated.  The  beat  is  somewhat 
irregular.  The  pulse  is  of  high  tension,  and  the  vessels  are 
thickened.  The  lungs  are  normal.  The  skin  acts  freely 
enough,  and  is  not  cedematous.  During  the  last  eight 
months  micturition  has  been  more  frequent  than  formerly, 
and  he  has  required  to  get  up  three  or  four  times  during 
the  night.  During  his  stay  in  the  Infirmary  the  daily 
quantity  of  urine  has  varied  from  60  to  90  ounces,  and 
the  specific  gravity  has  usually  been  about  1016  or  1017. 
The  albumen  has  varied  from  4-2  to  9*6  grammes  per  litre. 
The  microscope  has  revealed  the  presence  of  a  few  tube 
casts,  and  occasionally  some  blood  corpuscles.  The  daily 
discharge  of  urea  has  usually  been  between  300  and  450 
grains,  but  has  been  as  low  as  249  and  as  high  as  496 
grains.  There  is,  as  before  stated,  marked  impairment  of 
vision  in  both  eyes.  The  right  pupil  is  slightly  more  dilated 
than  the  left.  Ophthalmoscopic  examination  reveals  atrophy 
of  the  discs  following  upon  optic  neuritis.     In  the  right  eye 


80  ALBUMINUKIA. 

there  is  a  white  irregular  patch  at  the  macula,  with  small 
white  spots  round  it,  the  result  of  old  haemorrhages.  There 
is  a  line  of  haemorrhage  between  the  macula  and  disc,  and 
a  pigmented  spot  below  the  disc.  The  left  eye  shows  exten- 
sive partial  atrophy  of  the  choroid  at  its  lower  periphery, 
from  old  choroidal  disease.  The  patient,  as  a  result  of  his 
old  otorrhoea,  is  deaf  in  his  right  ear.  He  feels  the  pulsation 
of  the  arteries  in  his  head  in  a  disagreeable  way.  There  is 
nothing  else  worthy  of  notice  in  the  nervous  or  locomotary 
systems. 

There  can  be  no  doubt  as  to  what  the  condition  of  the 
kidneys  is.  You  have  had  many  opportunities  of  examining 
such  organs.  They  would  be  found  somewhat  reduced  in 
size,  perhaps  very  considerably,  and  not  necessarily  both  to 
the  same  extent,  for  the  disease  does  not  always  advance  pari 
passu  in  the  two  organs.  The  capsule,  being  adherent,  would 
be  separated  from  the  kidney  with  difficulty,  and  the  surface 
presented  would  be  uneven  and  granular,  with  numerous 
elevations  and  depressions.  On  cutting  it  open,  the  kidney 
would  feel  denser,  more  fibrous  than  usual,  and  on  section 
the  diminution  in  bulk  would  be  seen  to  be  mostly  towards 
the  surface.  On  microscopic  examination  the  fibrous  stroma 
would  be  found  much  increased.  The  tubules  would  show  in 
many  parts  no  trace  of  their  normal  structure,  but  would  be 
closed  up,  and  here  and  there  there  might  be  cystic  dilata- 
tions in  the  course  of  some  of  them.  The  Malpighian  tufts 
would  vary  in  size,  many  of  them  compressed  and  destroyed, 
their  capsules  greatly  thickened.  The  small  arteries  would  be 
thickened,  especially  in  their  middle  coat,  the  muscular  layer 
markedly  increased.  Throughout  the  body  generally  the 
vessels  would  show  considerable  sclerosis,  even  those  of  the 
size  of  the  radial  arteries.  The  left  side  of  the  heart  would 
exhibit  a  certain  amount  of  hypertrophy.  The  gastric 
mucous  membrane   would    show  some  evidence  of   catarrh. 


EARLY    RENAL    CIRRHOSIS.  81 

The  retina  would  exhibit  the  changes  characteristic  of  albu- 
minuric retinitis. 

This  case  affords  you  a  typical  instance  of  renal  cirrhosis 
as  we  see  it  at  the  stage  at  which  it  is  usually  diagnosed, 
and  you  will  observe  that  there  is  no  difficulty  in  making  it 
out,  but  the  case  is  otherwise  when  we  have  to  deal  with 
the  malady  in  its  incipient  or  early  condition.  I  cannot 
show  you  an  illustration  of  the  early  stage,  but  shall  describe 
a  case  which  I  have  had  under  observation  for  some  years. 
The  patient  is  a  gentleman  between  40  and  50,  who  says 
that  as  a  lad  he  had  knocked  about  the  world  a  great 
deal  and  taken  an  excess  of  alcohol,  but  from  about  the 
age  of  20,  while  living  freely,  he  had  not  exceeded.  He 
used  to  be  a  hard  rider,  many  hours  in  the  saddle  almost 
every  day.  When  about  40  he  felt  somewhat  out  of  health, 
and  on  examination  it  was  found  that  the  urine  was  of 
low  specific  gravity,  of  fully  normal  quantity,  and  con- 
tained a  slight  trace  of  albumen.  Very  careful  examin- 
ation elicited  no  additional  symptom.  There  was  no 
undue  tension  of  pulse,  no  enlargement  of  the  heart  or 
alteration  either  of  the  first  or  second  sound,  no  dimness 
of  sight,  nor  any  retinal  change.  Under  treatment  by 
regulation  of  diet  and  the  use  of  arsenic  the  condition 
improved,  the  albumen  entirely  disappearing  or  being  pre- 
sent only  in  faint  trace  now  and  then,  the  specific  gravity 
becoming  more  satisfactory,  the  amount  of  urea  coming  up 
to  nearly  a  healthy  standard,  and  all  feeling  of  unfitness 
disappearing.  But  now  and  again,  from  some  slight  cause, 
such  as  a  little  over-exertion  at  tennis  or  in  riding,  a  little 
business  anxiety,  or  such  like,  a  relapse  occurred,  and  for  a  few 
days,  or  perhaps  weeks,  there  would  be  a  recurrence  of  the 
symptoms.  I  have  watched  this  patient  through  a  number  of 
alarming  attacks,'  including  congestion  of  lung  with  consider- 
able fever,  and  temporary  paralysis  with  some  aphasia.    During 


8  2  ALBUMINURIA. 

the  febrile  attack  his  urine  became  highly  albuminous,  and 
tube  casts  were  present,  with  sometimes  a  few  blood  corpuscles, 
but  the  amount  of  urea  increased  considerably,  and  when  the 
fever  subsided,  the  urine  returned  to  its  ordinary  condition. 
The  nervous  seizure  was  of  quite  a  passing  kind,  but  was 
marked  by  numbness  in  one  arm  with  loss  of  power,  also  by 
twisting  of  face  from  some  paralysis  of  the  seventh  nerve,  and 
by  temporary  aphasia.  In  a  few  days  the  symptoms 
diminished,  and  ultimately  passed  away  entirely.  They  were 
probably  due  to  the  impaction  of  an  embolus,  which  gradu- 
ally disintegrated.  When  the  patient  resorts  to  a  warmer 
climate,  his  health  improves  in  every  respect,  the  urea  comes 
up  to  a  normal  standard,  the  albumen  almost  entirely  and 
constantly  disappears,  but  when  he  returns  to  this  country 
the  symptoms  become  less  favourable.  I  believe  that  this 
patient  suffers  from  renal  cirrhosis  in  a  comparatively  early 
stage,  and  that  during  the  febrile  attack  some  degree  of 
inflammation  of  the  tubules  became  superadded  to  it.  In  his 
usual  condition  the  patient  corresponds  pretty  closely  to  what 
Sir  Andrew  Clark (68)  has  happily  described  under  the  name 
of  Renal  Inadequacy,,  while  during  his  occasional  attacks  an 
actual  lesion  of  the  kidney  becomes  unmistakable. 

"What  you  have  seen  and  heard  to-day  may  suffice  to  give 
you  a  general  idea  of  the  clinical  features  of  cirrhosis  of  the 
kidneys.  But  in  order  to  give  you  anything  like  an  adequate 
knowledge  of  the  disease,  it  will  be  necessary  to  go  over  all 
the  systems  of  the  body,  and  explain  and  illustrate  the  vari- 
ous symptoms  and  complications  which  occur  in  each  as  the 
disease  advances. 

I  shall  conclude  this  lecture  by  inquiring  what  is  the 
cause  of  the  albuminuria  in  this  disease?  Of  the  four 
possible  causes  we  must  admit  that  perhaps  there  may 
be  alterations  in  the  blood  favouring  transudation  of  albu- 
men,  but   of  this  there   is    at  present    no  sufficient  proof. 


CAUSE    OF    ALBUMINURIA    IN    CIRRHOSIS.  83 

The  altered  state  of  trie  filtering  apparatus  is  obvious,  and  it 
is  certain  that  in  some  degree  these  changes  account  for  the 
production  of  the  symptom.  Increase  of  blood  pressure  from 
cardiac  hypertrophy  and  from  hindrance  to  the  course  of  the 
blood  through  the  organ  may  be  suspected  as  also  contribu- 
ting in  some  measure,  but  I  believe  that  the  chief  influence 
is  that  of  the  inflammatory  action  which  is  so  often  associ- 
ated with,  even  if  it  be  not  in  all  cases  an  essential  part  of 
the  cirrhotic  process.  The  inflammation  must  be  attended 
by  an  increased  transudation  from  the  vessels,  and  this  would 
account  at  once  for  the  slight  albuminuria  which  is  commonly 
present,  and  the  more  pronounced  discharge  which  makes  its 
appearance  occasionally  with  the  acute  exacerbations. 


LECTURE    VII. 

ALBUMINURIA  FROM  CIRRHOSIS  OF  KIDNEY— 

{continued). 

Clinical  Importance  of  the  Complications. — Gastric  Catarrh. — Con- 
stipation.— Morbid  States  of  Blood — Disorders  of  Circulation. 
—  Cardiac  Hypertrophy.  —  Degenerative  Changes.  —  Valvular 
Disease. — Pericarditis. — Changes  in  Arterial  Tension  and  in 
Vessels. — Disorders  of  Respiration. — Dyspnoea  from  Pidmonary 
Causes. — Urcemic  Dyspnoea. — Integumentary  System. — Dropsy. 

C\  ENTLEMEN, — When  I  gave  you  a  general  account  of 
the  clinical  features  of  cirrhosis  of  the  kidney,  I  told 
you  that  it  would  be  necessary  to  return  to  the  subject  when 
I  should  have  the  opportunity  of  pointing  out  some  of  the 
leading  complications  which  are  apt  to  arise  in  its  course. 
In  speaking  of  these  I  shall  refer  also  to  the  way  in  which 
the  different  complications  stand  related  to  other  forms  of 
renal  disease.  I  show  you  again  the  patient,  J.  S.,  and  ask 
you  to  notice  how  marked  is  the  disturbance  of  his  digestive 
system.  His  tongue  is  furred,  he  has  little  appetite,  and  his 
power  of  digestion  is  very  limited.  But  gastric  symptoms  of 
much  greater  severity  often  arise,  and  they  are  indeed  not 
unfrequently  dangerous  to  life.  I  recall  the  case  of*  a  gentle- 
man Avhom  I  saw  on  many  occasions  in  the  country,  and 
who  at  my  first  visit  had  so  severe  a  gastric  catarrh  that  he 
was  utterly  prostrated.  His  tongue  was  so  covered  with 
brown  fur  as  to  resemble  a  piece  of  drab  moleskin.  He 
loathed  food,  and  the  ingestion  even   of  a  little,  produced 

84 


G ASTRO-INTESTINAL    COMPLICATIONS.  85 

uneasiness  culminating  in  vomiting.  A  little  more  and  the 
patient  must  have  died.  But  in  this  case,  as  in  many 
others,  the  use  of  bismuth  with  soda  and  a  little  rhubarb 
and  aromatic  powder,  the  application  of  counter-irritants,  and 
careful  dieting  with  small  quantities  of  easily  digested  food 
— milk,  soups,  or  peptonised  preparations — and  the  use  of 
ice,  or  of  very  hot  water,  sufficed  to  give  relief,  and  the 
emergency  was  tided  over. 

Do  not  forget  that  besides  such  acute  or  subacute  attacks 
as  I  have  indicated,  the  gastric  digestion  is  always  more  or  less 
impaired,  and  the  dietary  consequently  requires  attention. 

The  state  of  the  intestines  is  often  of  much  importance. 
I  have  at  present  under  my  care  a  patient  suffering  from 
rather  advanced  cirrhosis  of  kidney,  with  disease  both  of  the 
valves  and  muscular  substance  of  the  heart,  who  suffered 
from  the  most  distressing  constipation,  with  painful  haemorr- 
hoids. This  patient's  journey  to  Edinburgh  was,  certainly  a 
very  hazardous  one,  considering  the  degree  of  debility  to 
which  he  was  reduced,  but  as  soon  as  the  constipation  had 
been  relieved,  the  immediate  danger  passed  away,  both  the 
kidneys  and  heart  improving  materially.  In  this  connection 
I  may  recall  to  you  the  case  of  Mrs.  K.,  whom  you  saw 
suffering  from  uraemia  in  the  Alexandra  Ward,  in  whom  the 
toxic  symptoms,  which  soon  became  fatal,  were  probably 
partly  due  to  the  prolonged  constipation  before  the  patient's 
admission  to  the  Infirmary. 

Functional  disturbance  of  the  liver  is  also  a  common  com- 
plication of  renal  cirrhosis  ;  but  organic  changes  of  that 
organ  are  less  frequent  than  we  might  expect. 

With  regard  to  the  gastro-intestinal  complications  in  other 
varieties  of  renal  disease,  you  will  find  the  later  stages  of 
nephritis  correspond  very  closely  to  cirrhosis.  Sometimes 
digestion  is  extremely  impaired  in  the  earlier  stages  of  that 
disease   also.      Diarrhoea  is  not   common   in   nephritis,  and 


86  ALBUMINURIA. 

affections  of  the  liver  are  quite  exceptional.  With  waxy 
degeneration  of  the  kidney  the  case  is  quite  otherwise,  for 
very  intractable  dyspepsia,  sometimes  attended  by  haema- 
temesis,  is  occasionally  seen,(69)  and  diarrhoea  is,  of  course,  the 
best  known  symptom  of  the  degeneration  as  it  affects  the 
intestine.  Haemorrhage  also  sometimes  occurs  from  this 
source,  a  result  either  of  simple  rupture  of  vessels  or  of 
ulceration.  The  liver  frequently  exhibits  the  characteristics 
of  waxy  degeneration  or  syphilitic  disease. 

Passing  now  to  the  hemopoietic  system  we  find  that 
deterioration  of  the  blood  may  also  be  an  important 
element  in  these  cases.  I  have  seen  a  patient  in  great  peril 
from  anaemia  due  to  actual  haemorrhage.  Epistaxis  is  the 
most  common  variety.  Sometimes  it  appears  as  an  early 
symptom,  more  frequently  as  a  late  one.  Some  of  you  may 
remember  in  this  connection  that  in  the  case  of  A.  C,  which 
we  studied  at  the  bedside,  and  to  which  I  shall  afterwards 
have  to  refer  in  relation  to  cerebral  haemorrhage,  there  was 
a  history  of  a  severe  attack  of  epistaxis  six  months  before 
admission  to  the  Infirmary.  Sometimes  there  is  a  continuous 
oozing,  which  may  be  relieved  or  kept  in  check  by  the 
insufflation  of  styptics,  at  others  a  gush  so  considerable  as 
to  require  plugging  of  the  nares. 

Some  of  your  predecessors  studied  with  me  the  case  of  a 
woman  who  had  haemorrhages  not  only  from  the  Schneiderian 
membrane,  but  into  the  conjunctivae,  the  eyelids,  and  other 
parts  of  the  face ;  and  occasionally  you  will  meet  with 
haemorrhage  from  other  sources,  as  from  the  uterus  or 
the  bowel.  The  haemorrhages  into  the  retina  and  into  the 
brain  substance  fall  to  be  considered  in  another  connection. 
Occasionally  haemorrhage  from  the  urinary  tract  itself  com- 
plicates the  disease,  for  pretty  copious  bleeding  may  occur 
from  the  kidney,  and  sometimes  I  suspect  from  the  prostate 
or  from  the  vesical  mucous  membrane. 


MORBID   STATES    OF    BLOOD.  87 

I  have  satisfied  myself  that  hemoglobinuria  is  sometimes 
associated  with  this  condition  of  kidney,  and  generally  as 
an  early  symptom. 

Apart  from  considerable  haemorrhages,  a  deficiency  of 
corpuscles  and  haemoglobin  is  very  common.  In  the  blood 
of  J.  S.,  the  haemoglobin  is  only  40  to  48  per  cent.,  and  the 
corpuscles  were  once  found  only  a  little  over  3,000,000  in 
the  cubic  millimetre. 

But  blood  changes  of  the  kind  that  I  have  discussed  are 
for  the  most  part,  like  this  accumulation  of  urea  or  other 
waste  products,  secondary  to  the  renal  malady.  Changes  of 
another  kind,  such  as  increase  of  uric  acid,  often  precede 
and  probably  cause  the  renal  irritation. 

In  nephritis  the  blood  shows  a  marked  tendency  to  rapid 
deterioration,  the  specific  gravity  falling,  the  total  solids 
becoming  diminished,  the  haemoglobin  and  corpuscles  rapidly 
becoming  less  during  the  earlier  stages.  Later  on  in  the 
history  of  the  case  the  same  condition  persists,  but  I  have 
rarely  seen  so  marked  a  tendency  to  haemorrhage  as  in  cirr- 
hosis. In  waxy  degeneration  the  blood  is  often  in  an 
unsatisfactory  condition  from  causes  other  than  the  renal.  I 
have  sometimes  seen  a  slight  increase  of  white  corpuscles, 
and  a  flabbiness  of  the  red  with  tendency  to  tail,  especially 
where  the  spleen  or  lymphatic  glands  were  involved. 

Complications  involving  the  circulatory  and  respiratory 
systems  are  among  the  most  important  of  all. 

In  illustration  of  the  cardiac  changes  I  shall  show  you 
examples  of  cardiac  hypertrophy,  cardiac  failure,  and  of  chronic 
endocardial  disease,  and  shall  recall  to  you  a  case  of  pericard- 
itis. You  observe  that  in  the  case  of  J.  S.  there  is  no  marked 
hypertrophy  of  heart,  but  that  the  second  sound  is  distinctly 
accentuated  in  the  aortic  area.  In  this  other  patient  you 
observe  the  widely  extended  and  well  pronounced  apex  beat, 
and  you  hear  that  the  cardiac  dulness  extends  beyond  the 


88  ALBUMINURIA. 

line  of  the  left  nipple,  while  not  only  is  the  aortic  second 
sound  accentuated,  but  the  first  sound  is  booming  and 
prolonged.     Here  we  have  evidence  of  marked  hypertrophy. 

So  far  as  I  have  been  able  to  make  out,  the  more  advanced 
the  renal  malady  is,  the  more  pronounced  are  these 
symptoms,  and  I  regard  them  as  true  examples  of  con- 
sequent complications.  In  a  series  of  cases  which  I  tabu- 
lated many  years  ago  I  found  that  cardiac  hypertrophy 
was  more  common  in  cirrhosis  than  in  the  other  renal 
diseases,  and  that  generally  speaking  the  more  advanced 
the  atrophy  the  more  distinct  it  was.  The  experience  of  my 
friend  Professor  Kosenstein(vo)  and  other  reliable  observers 
brings  out  the  same  result.  As  to  the  explanation  of  the 
cardiac  hypertrophy,  it  is  to  be  referred  partly  to  the  obstruc- 
tion of  the  renal  circulation  inevitable  in  the  disease,  partly, 
no  doubt,  to  the  widespread  disease  of  arteries,  arterioles 
and  capillaries,  partly  to  the  greater  difficulty  experienced 
by  the  heart  in  its  efforts  to  drive  an  impure  blood  through 
the  vascular  system,  perhaps  in  part  also  to  the  spasmodic 
contraction  of  the  small  vessels  as  suggested  by  Dr.  George 
Johnson.(71) 

I  turn  now  to  two  cases  illustrative  of  failure  of  the 
cardiac  muscle,  for  the  hypertrophy  with  strong  action 
may  be  followed  by  degenerative  changes  in  the  muscular 
substance  of  the  heart,  consequent  failure  of  its  power,  and 
diminution  of  strength  and  tension  in  the  pulse.  Some 
of  you  have  seen  a  patient  who  is  in  the  private  ward,  and 
who  has  suffered  from  very  distressing  cardiac  symptoms 
in  the  course  of  his  renal  cirrhosis.  Indeed,  he  sought  advice 
not  on  account  of  kidney  disease,  but  for  the  heart.  Its 
action  was  tumultuous  and  irregular,  at  times  very  rapid ;  the 
pulse  beat  was  rather  feeble,  and  the  tension  was  diminished. 
Physical  examination  showed  that  the  heart  was  dilated,  and 
that  its  walls,  although  feeble,  were  abnormally  thick.    Under 


CARDIAC    CHANGES.  89 

treatment  by  means  of  rest,  careful  and  nutritious  dieting, 
and  the  use  of  cardiac  tonics — digitalis  and  strophanthus — 
"he  has  greatly  improved,  the  action  having  become  steady 
and  regular,  and  the  pulse  firm  and  of  good  tension.  In  this 
other  case,  however,  along  with  a  degree  of  thickening  of  the 
vessel  walls,  a  firm  beat  with  great  vascular  tension,  we  find 
dyspnoea  upon  exertion,  and  other  tokens  of  cardiac  debility. 
How  is  this  apparent  contrariety  of  symptoms  to  be  explained  ? 
The  explanation  lies  in  the  fact  that  the  degeneration  and 
consequent  dilatation  may  not  affect  the  whole  heart  equally 
but  especially  certain  parts  of  it,  and  that  in  some  cases  it  is 
the  right  side  of  the  heart  which  is  mainly  affected.  From 
the  comparative  thinness  of  the  wall  of  the  right  ventricle, 
it  is  evident  that  in  such  morbid  conditions  it  is  more  liable 
to  dilatation  and  failure  than  the  left  venticle.  The  explana- 
tion which  I  give,  therefore,  is  that  while  the  left  ventricle 
continues  strong  enough  to  maintain  a  high  tension  of  pulse 
and  a  firm  beat,  the  right  ventricle  has  become  so  much 
degenerated  and  dilated  that  it  is  unable  sufficiently  to  per- 
form its  function  of  driving  the  blood  through  the  lungs. 
This  explanation  is  not  definitely  proved,  but  it  is  almost 
certain  that  it  is  correct. 

Patients  suffering  from  cirrhosis  of  the  kidney  are  very 
liable  to  valvular  disease  of  the  heart.  This  constitutes  a 
formidable  complication,  and  should  always  be  carefully 
looked  for.  I  show  you  to-day  a  patient,  J.  G.,  who  has 
cirrhosis  of  kidney  with  some  tubular  inflammation  super- 
added, and  who  is  greatly  troubled  with  dyspnoea.  That 
dyspnoea  is  in  part  due  to  pulmonary  changes  of  which 
I  shall  speak  presently,  but  is  also  in  part  to  be  ascribed 
to  the  valvular  lesions.  On  auscultation  we  find  a  systolic 
mitral  and  a  diastolic  aortic  murmur,  and  there  is  probably 
also  a  systolic  tricuspid  murmur.  There  is,  therefore,  both 
mitral  and  aortic  incompetence,  and  probably  some  tricuspid 


9  0  ALBUMINURIA. 

incompetence  as  well.  You  will  at  once  perceive  how  greatly 
the  difficulty  of  dealing  with  this  case  is  increased  by  the 
existence  of  such  complications.  I  cannot  give  you  any 
proof  that  endocarditis  results  from  the  renal  lesion,  although 
they  so  often  coexist. 

But  there  is  another  cardiac  complication — viz.,  peri- 
carditis. When  this  extremely  grave  condition  occurs, 
the  patient  is  observed  to  be  seriously  ill,  and  is  usually 
seized  with  severe  pain,  which  may  be  referred  to  the 
prsecordia,  the  scrobiculus  cordis,  or  to  some  position 
lower  in  the  abdomen.  Friction  is  heard  over  the  heart, 
and  it  is  not  an  indistinct  friction  such  as  might  be  over- 
looked, but  very  marked  and  unmistakable.  The  pulse  soon 
loses  its  tension,  and  the  beat  becomes  weak.  There  may  be 
superadded  the  signs  of  effusion  into  the  pericardium.  Peri- 
carditis is  most  apt  to  occur  when  the  case  is  far  advanced, 
and  it  usually  speedily  leads  to  a  fatal  issue.  Some  of  you 
may  remember  the  case  of  a  patient  who  was  in  the  Paton 
Ward  suffering  from  cirrhosis  and  slight  tubular  inflammation 
of  the  kidneys.  In  his  case,  not  only  was  there  pericarditis 
shortly  before  death,  but  there  had  been  a  previous  attack  of 
pericarditis  as  well,  for  at  the  autopsy  it  was  found  that  in 
addition  to  the  soft  recent  adhesions,  the  pericardium  was 
thickened  from  old  inflammation. 

Besides  the  lesions  in  the  heart,  a  variety  of  changes 
occur  in  other  parts  of  the  circulatory  system,  the  increase 
of  arterial  tension  and  the  thickening  of  the  vessel  walls  being 
the  most  important.  The  increased  tension  becomes  as  a 
rule  more  marked  as  the  disease  advances,  and  is  due,  on  the 
one  hand,  to  obstruction  in  the  smaller  vessels,  and  on  the 
other,  to  the  increased  cardiac  action.  As  to  the  thickening 
of  the  vessels,  my  observations  confirm  the  statement  of  Dr. 
George  Johnson  that  it  is  situated  mainly  in  the  middle  coat 
of  the  smaller  arteries,  a  consequent  complication  of  chronic 


ARTERIAL    CHANGES.  91 

renal  disease.  But  it  must  also  be  admitted  that  alterations 
of  the  inner  and  outer  coats  are  common,  and  that  the 
thickening  and  tortuosity  of  arteries  are  often  due  to  them. 
So  important  is  this  relationship,  that  Sir  William  Gull  and 
Dr.  Sutton (72)  have  come  to  the  conclusion  that  a  vascular 
change,  which  they  designate  arterio-capillary  fibrosis,  is  the 
real  starting-point  of  the  process  rather  than  a  renal  lesion. 
It  is  certain  that  this  change  is  commonly  associated  with 
the  disease.  It  is  also  certain  that  changes  around  the 
blood-vessels  often  constitute  the  first  observed  lesion  in  the 
kidney  itself,  and  in  many  cases  not  the  minute  vessels  alone, 
but  vessels  of  the  size  of  the  radial  arteries  and  upwards 
show  the  change.  But  on  the  other  hand,  arterio-capillary 
fibrosis  often  exists  without  any  renal  cirrhosis.  The  lesion 
observed  in  the  kidney  is  very  often  a  simple  overgrowth  of 
the  interstitial  tissue,  not  specially  perivascular,  and  the 
degree  of  change  in  the  vessels  varies  so  much  that  it  cannot 
be  held  to  stand  in  close  and  constant  relationship  to  the 
state  of  the  kidney. 

The  circulatory  system  also  becomes  altered  in  cases  of 
nephritis.  Dr.  Mahomed (73)  thought  that  before  albumen 
appeared  in  the  urine  the  arterial  tension  was  already 
increased,  and  that  its  occurrence  might  be  predicted  by  the 
rise  of  tension  in  the  pulse.  I  have  not  been  able  to  confirm 
his  statements  by  my  own  observations.  On  the  contrary, 
they  show  that  tension  follows  upon  renal  lesion,  and  within 
certain  limits  I  should  say  that  the  longer  the  nephritis  lasts 
the  more  marked  does  the  tension  become.  It  is  usually  well 
marked  within  a  few  weeks  of  the  commencement  of  inflam- 
mation, and  in  long-standing  cases  is  as  pronounced  as  it  is 
in  cases  of  cirrhosis,  unless  there  is  something  to  interfere 
with  the  development  of  cardiac  hypertrophy.  That  hyper- 
trophy itself  you  may  often  have  opportunity  of  watching  in 
process   of  development,  and  you  will   find   that   the   more 


9  2  ALBUMINURIA. 

advanced  a  case  of  nephritis  is,  the  more  distinct  does  it 
become.  In  a  series  of  cases  which  I  tabulated  many  years 
ago,  I  found  on  post-mortem  examination  that  it  was  present 
in  12*5  per  cent,  of  cases  fatal  in  the  first  stage,  in  38'5  of 
those  fatal  in  the  second,  and  in  100  per  cent,  of  those  fatal 
in  the  third. 

Valvular  lesions  are  not  such  common  accompaniments  of 
nephritis  as  they  are  of  cirrhosis,  and  the  retrogade  metamor- 
phic  changes  in  the  muscular  substance  of  the  heart  have  also 
occurred  less  frequently  in  my  practice.  Pericarditis  I  have 
met  with  occasionally,  especially  in  the  second  and  third 
stages  of  the  process. 

Cardiac  and  arterial  tension  changes  are  by  no  means  com- 
mon accompaniments  of  waxy  disease.  In  my  series  of  waxy 
cases  they  occurred  only  in  5  per  cent,  of  the  far  advanced 
cases,  in  no  case  fatal  in  the  earlier  stage.  Even  when 
present,  they  are  not  very  pronounced.  Changes  in  the 
smaller  vessels  are,  of  course,  very  frequent. 

Symptoms  and  complications  affecting  the  respiratory 
system  are  of  frequent  occurrence  in  cases  of  renal  disease, 
and  dyspnoea  in  particular  often  causes  great  distress. 
Sometimes  it  comes  on  gradually,  at  others  with  great 
abruptness.  Sometimes  the  air  is  found  to  be  entering 
the  lungs  quite  freely,  at  others  its  entrance  is  impeded. 
It  may  depend  on  various  causes.  I  shall  speak  first  of 
those  proceeding  from  the  pleurae  and  the  lungs. 

Serous  effusion  into  the  pleural  sacs  takes  a  foremost 
place,  and  you  should  in  every  case  where  dyspnoea  occurs 
make  careful  search  for  evidence  of  this  change.  It  may 
appear  when  there  is  no  dropsical  effusion  elsewhere,  or 
coexist  with  anasarca.  It  may  come  on  gradually  and  make 
the  most  insidious  progress,  or  it  may  develop  very  quickly. 
Whenever  there  is  dyspnoea,  and  even  a  thin  line  of  dulness 
at  the  base  of  the  pleurse  posteriorly,  you  should  carefully 


PULMONARY    CHANGES.  93 

examine  the  axillary  region,  introduce  your  exploring  needle, 
and  make  sure  whether  fluid  is  present  or  not. 

Conditions  affecting  the  lungs  themselves  are  also  very 
important.  Chief  among  them,  I  must  mention  venous 
congestion  and  consequent  oedema — the  latter  indicated  by  a 
degree  of  impairment  of  the  percussion-note  over  the  bases  of 
the  lungs  posteriorly,  with  crepitations  heard  on  auscultation. 
As  a  rule  this  complication  develops  gradually,  sometimes, 
however,  with  great  rapidity. 

A  few  years  ago  a  gentleman  from  Perthshire,  who  was 
living  in  one  of  the  Edinburgh  hotels,  was  suddenly  seized  with 
dyspnoea.  He  was  seen  by  an  accomplished  and  experienced 
practitioner,  who  found  the  general  evidences  of  acute  bron- 
chitis, with  oedema  of  the  lung,  and  prescribed  the  remedies 
ordinarily  employed  in  such  cases  ;  but  in  the  course  of  a  few 
hours  the  condition  had  become  much  worse,  and  the  patient 
died  before  the  practitioner  could  again  see  him.  A  legal 
question  of  considerable  interest  arose  in  regard  to  the 
destination  of  his  property,  for  he  had  bequeathed  it  by  a  will 
made  not  very  long  before  his  fatal  illness,  and,  as  the  law 
then  stood,  the  will  was  not  valid  if  at  the  time  of  its  execu- 
tion the  patient  was  already  suffering  from  the  disease  of 
which  he  died.  The  opinion  of  various  medical  men  was 
asked  as  to  whether  the  patient  died  of  an  independent  pul- 
monary malady,  or  of  a  suddenly  developed  sequel  of  chronic 
renal  disease.  Dr.  Rutherford  Haldane  and  I  happened  to 
be  among  those  consulted,  and  we  found  evidence  that  symp- 
toms had  existed  for  a  considerable  time  which  pointed  to 
cirrhosis  of  the  kidney,  and  came  to  the  conclusion  that, 
although  there  was  no  autopsy,  we  yet  were  entitled  to  con- 
clude that  the  death  resulted  from  pulmonary  oedema  second- 
ary to  renal  disease.  This  case  may  illustrate  the  sudden 
onset ;  you  have  seen  in  the  wards  many  instances  of  a  more 
gradual  invasion. 


94  ALBUMINURIA. 

Very  urgent  symptoms  may  arise  also  from  oedema 
higher  up  in  the  respiratory  tract — namely,  at  the  glottis. 
This  may  come  on  suddenly  from  slight  exposure  to  cold, 
and  it  may  be  so  severe  as  to  demand  operative  interference. 

A  patient  of  mine  in  the  Old  Infirmary  was  recovering 
from  an  attack  of  nephritis,  and  had  got  so  well  as  to  be 
allowed  to  go  out  to  visit  some  of  her  friends.  Waiting  for 
an  omnibus  at  the  corner  of  Infirmary  Street  she  got  chilled, 
and  the  same  evening  was  taken  with  such  dyspnoea  from 
oedematous  inflammation  of  the  glottis  that  tracheotomy 
became  necessary.  This  was  performed  by  my  house-physi- 
cian, Dr.  Coldstream,  now  of  Florence,  and  the  girl  was 
rescued  from  most  imminent  danger.  Such  an  incident  is 
more  likely  to  arise  in  connection  with  the  acuter  processes, 
but  may  occur  even  in  chronic  renal  maladies. 

Dyspnoea  may  be  due  to  bronchitis  and  pneumonia  ;  and 
I  may  just  recall  to  your  minds  the  grave  symptoms  which 
may  arise  from  the  occurrence  of  pulmonary  apoplexy.  You 
are  aware  also  of  the  tendency  to  serous  inflammation  which 
exists  in  Bright's  disease,  and  sometimes,  though  less  fre- 
quently than  the  pericardium,  the  pleurae  are  so  affected 
and  dyspnoea  may  result  therefrom. 

Embarrassment  of  respiration  also  results  from  the  toxic 
state  of  the  blood,  being  one  of  the  important  manifestations 
of  uraemia.  In  the  absence  of  cardiac  degeneration  or  pul- 
monary change  the  symptom  may  be  suddenly  developed, 
and  in  either  of  two  forms.  The  one  variety,  induced  by  an 
action  upon  the  respiratory  centre,  occurs  just  as  the  case  is 
approaching  its  fatal  termination.  I  may  illustrate  it  by  an 
instance  met  with  some  years  ago.  I  went  to  visit  a  patient 
in  the  south  of  Scotland,  whose  kidneys  were  not  known 
to  be  diseased.  When  I  arrived  he  was  breathing  rapidly 
and  laboriously,  but  the  air  was  entering  the  lungs  freely, 
and  there  was  no  sign  of  pulmonary  or  cardiac  change,  the 


UREMIC    DYSPN(EA.  95 

pulse  was  tense,  and  the  other  symptoms  of  cirrhosis  of  the 
kidney  were  present,  so  that  we  had  manifestly  to  do  with  a 
pure  and  simple  example  of  ursemic  dyspnoea,  and  it  rapidly 
went  on  to  a  fatal  result.  This  form  is  due  to  poisoning  of 
the  respiratory  centres  by  the  toxic  substances  which  the 
kidneys  have  failed  to  eliminate.  The  other  variety  occurs 
in  the  form  of  temporary  attacks,  closely  resembling  ordinary 
asthma.  The  patient  is  awakened  perhaps  at  one  or  two 
o'clock  in  the  morning  with  a  fit  of  coughing,  and  in  a  state 
of  most  distressing  dyspnoea.  After  a  time  he  expectorates 
some  mucus,  perhaps  tinged  with  blood,  and  then  he  is* 
relieved  for  the  time.  This  variety  appears  to  be  due  to 
irritation  of  the  bronchi  by  the  poisoned  blood,  and  one 
cannot  avoid  suspecting  that  a  cardiac  element  also  is 
associated  with  it. 

Effusion  into  the  pleura  is  an  important  source  of  danger 
in  cases  of  nephritis,  in  which  dropsy  is  so  common.  (Edema 
of  lungs,  bronchitis,  pneumonia,  and  pleurisy,  are  all  occa- 
sionally met  with,  but  they  play  a  less  important  part  in  its 
clinical  history  than  in  that  of  cirrhosis.  The  only  really 
important  pulmonary  complication  of  waxy  kidney  is  phthi- 
sis, and  that  is  a  cause  of  the  process. 

The  integumentary  system  shows  a  dryness,  occasionally 
an  itching,  and  a  certain  tendency  to  dropsy.  In  a  pure 
case  of  renal  cirrhosis  there  may  be  practically  no  swelling, 
but  whenever  a  degree  of  inflammation  of  tubules  becomes 
superadded,  dropsy  appears.  It  also  frequently  takes  origin 
from  cardiac  weakness  or  from  valvular  disease.  I  must 
defer  the  consideration  of  the  nervous  changes  to  another 
lecture. 


LECTURE    VIII. 

ALBUMINURIA  FROM  CIRRHOSIS  OF  KIDNEY— 

continued. 

Headache. — Its  Varieties. — Dimness  of  Vision. — Urcemic. — Due  to 
organic  causes. — Retinal  Haemorrhage. — Albuminuric  Retini- 
tis.—  Uraemia. — Acute. — Illustrative  Case. — Chronic. — Different 
Forms  of  Symptoms. — Illustrative  Case. — Causation  of  Urae- 
mia.— Paralysis  and  Aphasia. — Illustrative  Cases. — Remarks. 

C\  ENTLEMEN, —  Resuming  the  consideration  of  the  com- 
plications  of  renal  cirrhosis,  which  we  partially  over- 
took on  a  recent  occasion,  I  purpose  to  devote  this  hour  to 
giving  you  some  account  of  the  affections  of  the  nervous 
system  which  are  apt  to  arise  in  the  course  of  the  malady. 

General  deterioration  of  the  nervous  system  seems  to  me 
always  to  attend  upon  renal  cirrhosis,  showing  itself  by 
irritability  of  temper,  restlessness,  diminution  of  power  of 
sustained  attention,  consequent  failure  of  working  power, 
impairment  of  memory  and  of  the  soundness  of  judgment, 
with  perhaps  an  increased  susceptibility  to  the  action  of 
alcohol,  and  of  nervine  drugs.  These  conditions,  resembling 
what  one  often  notices  after  sunstroke  or  injuries  to  the 
head,  mark  an  interference  with  the  nutrition  of  the  cerebral 
substance  which  the  observant  physician  can  often  make  out 
even  in  the  early  stage,  and  almost  certainly  in  the  later 
stages  of  the  disease. 

Among  the  subjective  symptoms,  headache  and  dimness 

of  sight  are  the  most  frequent.     The  headache  is  sometimes 
96 


HEADACHE.  97 

distressing,  and,  while  it  may,  with  sickness  and  morning 
vomiting,  usher  in  a  fatal  uraemia,  it  may  be  habitual,  recur- 
ring at  intervals  throughout  a  period  of  months  or  even 
years.  Sometimes  it  is  intense,  fixed  mainly  in  one  locality, 
and  apparently  neuralgic  ;  sometimes  it  is  widely  distributed 
throughout  the  skull,  and  patients  may  describe  it  to  you 
as  a  diffused,  splitting  headache;  sometimes  it  is  frontal, 
sometimes  occipital.  Often  it  is  aggravated  with  each  throb 
of  the  hypertrophied  heart.  I  think  that  it  may  be  due  to 
different  causes.  It  may  be  neuralgic  or  anaemic,  may  result 
from  poisoning  by  non-eliminated  tissue  products,  or  may  be 
due  to  organic  change,  especially  in  the  blood-vessels.  In 
the  case  of  J.  S.,  whom  I  again  show  you  to-day,  this  was 
the  earliest  symptom.  You  remember  how  he  told  us  that 
he  was  distressed  by  headache,  especially  when  passing 
through  hot  regions,  such  as  the  Eed  Sea.  It  is  now  less 
troublesome,  although  he  is  not  entirely  free  from  it. 

The  impairment  of  vision  also  presents  a  considerable 
variety  in  its  clinical  features.  There  may  be  sudden  dim- 
ness of  sight  or  actual  blindness.  It  may  affect  the  whole 
field  of  vision  or  only  a  part.  It  may  be  associated  with 
headache  or  with  other  uraemic  manifestations,  or  may  occur 
alone.  It  is  commonly  transitory,  lasting  an  hour  or  two, 
perhaps  a  day,  and  reminding  one  of  the  dimness  of  sight 
sometimes  accompanying  megrim,  or  the  temporary  hemi- 
anopsia of  some  cases  of  brain  syphilis.  The  pupils  show  no 
peculiarity,  and  the  fundus  of  the  eye  is  quite  normal.  This 
is  the  uraemic  blindness.  The  attack  may  be  precipitated  by 
incidental  circumstances,  perhaps  gastric  derangement,  and 
it  does  not  necessarily  herald  the  immediate  fatal  termina- 
tion of  the  case. 

But  dimness  of  vision  is  often  due  to  organic  causes. 
You  observe  that  J.  S.  has  the  peculiar  vague  and  vacant 
expression  of  an  amaurotic  patient.     His  eyes  do  not  focus 

H 


9  8  ALBUMINURIA. 

themselves  readily  upon  objects.  His  pupils  are  dilated. 
It  is  now  many  months  since  he  began  to  notice  his  sight 
failing.  He  required  a  brighter  light  when  reading,  and 
reading  small  type  gradually  became  impossible.  Objects 
appeared  indefinite,  blurred,  and  indistinct.  On  ophthalmo- 
scopic examination  some  of  you  have  already  seen  the  condi- 
tion of  his  retinse.  Perhaps  they  are  less  characteristic  than 
those  of  this  patient  (J.  G.),  but  from  the  two  you  can  have 
opportunity  of  fully  satisfying  yourselves  as  to  the  retinal 
changes  which  occur  in  this  disease.  You  will  find  that 
there  are  haemorrhages,  patches  varying  in  size,  some  of 
a  deep  and  some  of  a  lighter  red  colour.  You  notice 
also  fawn-coloured  or  fatty  patches,  and  some  portions 
that  are  white  and  completely  atrophied.  You  will  notice 
also  the  distribution  of  white  radiating  lines,  corresponding 
to  the  inflammatory  changes  in  the  fibrous  tissue  of  the 
structure.  You  notice  that  both  eyes  are  affected,  but 
usually  not  in  the  same  parts  or  to  the  same  extent.  This 
is  of  great  interest,  not  only  in  itself,  but  as  an  evidence 
that  organic  changes  of  a  minute  kind  may  arise  in  other 
parts  of  the  nervous  system  in  the  course  of  renal  maladies. 
The  organic  eye  changes  generally  herald  very  serious  head 
symptoms,  but  they  may  last  for  considerable  periods,  and 
indeed  partial  recovery  may  take  place  after  they  have  been 
fairly  established.  Especially  in  the  albuminuria  of  preg- 
nancy does  one  find  these  symptoms  prove  less  formidable. 
I  have  known  them  almost  entirely  disappear  after  delivery. 

The  eye  symptoms  are  much  less  common  in  nephritis 
than  in  cirrhosis,  but  are  occasionally  seen  in  the  early,  and 
not  unfrequently  in  the  later  stages.  They  are  rare  in  waxy 
disease,  occurring  only  in  cases  of  long  standing,  and  even 
there  not  to  a  great  extent. 

Ursemic  symptoms  include  not  only  those  to  which  we 
have  already  referred — the  dyspnoea  and  the  blindness,  but 


UREMIA.  9  9 

a  great  variety  of  other  conditions.  There  is  acute  uraemia 
with  coma  and  convulsions.  It  may  occur  in  acute  inflam- 
matory disease  of  the  kidneys,  as  in  the  first  case  which  I 
showed  you  when  speaking  of  that  subject.  It  may  occur  in 
old-standing  inflammatory  cases,  is  not  uncommon  in  cirr- 
hosis, and  is  met  with,  although  rarely,  in  waxy  disease.  I 
remember  a  patient  coming  to  me  on  account  of  an  epileptic 
seizure.  He  had  been,  as  he  supposed,  in  good  enough  health, 
was  in  a  shop  transacting  business,  when  suddenly  he  fell 
down  in  a  convulsion,  and  thereafter  remained  for  some  time 
unconscious.  When  I  examined  him  it  was  clear  that  he  had 
somewhat  advanced  cirrhosis  of  the  kidney.  The  fit  did  not 
recur,  and  after  a  time  he  came  stating  that  he  had  been 
engaged,  and  wishing  to  know  whether  he  would  be  justified 
in  marrying.  He  was  not  a  young  man,  and  the  lady  of  his 
choice  was  of  an  age  well  suited  to  his  own,  and  I  said  that 
if  the  circumstances  and  the  danger  of  a  sudden  termination 
were  fully  explained,  and  if  proper  precautions  as  to  health 
were  afterwards  taken,  I  thought  that  he  might  marry.  His 
health  continued  fair  for  a  year  or  more  after  the  event,  and 
then  the  inevitable  termination  came.  The  fits  recurred ;  he 
passed  into  a  state  of  coma,  with  stertorous  breathing,  and 
when  the  coma  had  persisted  for  about  two  days,  with  occa- 
sional violent  convulsions,  he  died. 

In  that  case  I  had  no  clue  to  an  explanation  of  the  sudden 
early  attack.  Sometimes  the  explanation  is  definite  enough. 
I  once  attended  a  commercial  traveller  whose  kidneys  were 
cirrhotic,  but  who  was  obliged  to  continue  his  work  on  the 
road.  When  at  home  he  generally  managed  to  resist  the 
temptations  of  liquor,  but  occasionally  in  a  country  town  its 
attractions  proved  irresistible.  When  he  had  taken  a  little 
he  used  to  become  excited,  and  then  an  attack  of  convulsions 
with  coma  occurred.  More  than  one  of  my  professional 
brethren  in  different  country  towns  had  the  responsibility  of 


100  ALEUMINUEIA. 

treating  him  under  these  conditions.  He  used  to  recover  in 
a  day  or  two.  and  then,  leading  an  abstemious  life  for  a  time, 
he  enjoyed  fair  health.  He  ultimately  went  to  live  in 
England,  and  I  lost  sight  of  him.  But  there  were  three 
causal  elements  in  his  case.  His  constitution  was  neurotic, 
his  renal  disease  was  considerably  advanced,  and  a  little 
indulgence  in  liquor  sufficed  to  precipitate  the  attack. 

Sometimes  coma  and  convulsions  never  appear  till  they 
usher  in  the  fatal  result.  I  was  once  called  to  see  a  lady 
who  had,  while,  as  was  supposed,  in  the  enjoyment  of  good 
health,  suddenly  become  convulsed,  and  passed  into  a  state 
of  coma.  I  found  her  actually  dying.  She  was  pale  and 
of  a  grey  complexion.  A  cold  perspiration  covered  her 
skin.  Her  person  had  a  somewhat  urinous  odour,  and  I 
found  reason  to  think,  as  was  afterwards  confirmed  by  post- 
mortem examination,  that  the  kidneys  were  extensively  dis- 
eased from  cirrhosis  with  cystic  degeneration.  Thus  you  see 
that  the  patient  may  die  even  in  the  first  attack.  Still,  the 
prognosis  is  not  so  unfavourable  in  acute  as  in  chronic 
uraemia.  Treatment  by  diaphoretics,  such  as  jaborandi, 
pilocarpin,  hot-air  baths,  or  by  purgatives,  sometimes  by 
venesection,  may  give  good  results.  Sometimes  the  attack 
passes  off  without  active  treatment  at  all. 

It  is  otherwise  in  the  great  majority  of  cases  with  chronic 
uraemia.  The  patient  has  had  his  renal  lesion  for  a  long 
time,  and  his  whole  system  has  become  deteriorated.  He 
begins  to  be  listless,  disinclined  to  rise,  complains  of  lassi- 
tude, and,  perhaps,  a  little  sore  throat.  His  articulation 
becomes  indistinct,  like  that  of  a  person  slightly  intoxicated. 
He  takes  little  notice  of  what  goes  on  around  him.  Gradu- 
ally the  listlessness  passes  into  torpor,  he  is  roused  only 
when  loudly  spoken  to,  and  when  you  *  ask  after  his  health, 
he  probably  assures  you  that  he  is  quite  well.  His  torpor 
passes  into  coma.     He  lingers  on  for  days,  perhaps  for  more 


U1LEMIA.  101 

than  a  week,  and  at  last  dies,  sometimes  with  and  sometimes 
without  convulsions.  Almost  invariably  this  process  leads 
up  to  death.  Once  or  perhaps  twice  have  I  seen  a  patient 
rally  from  it. 

In  other  cases  I  have  known  the  gradually-increasing 
torpor  associated  with  noisiness  and  with  delirium.  I  have 
known  a  ward  disturbed  for  days  with  the  occasional  occur- 
rence of  a  loud  prolonged  howl  uttered  by  a  patient  who,  as  a 
rule,  lay  quiet,  and  only  now  and  then  started  up  in  a  par- 
oxysm of  maniacal  excitement.  Sometimes  there  is  inces- 
sant loquacious  restlessness,  with  wild  excitability,  and  to 
this  again  convulsions  may  be  superadded. 

Many  of  you  have  had  the  opportunity  of  seeing  several 
examples  of  the  head  symptoms  of  renal  disease  in  the  wards 
during  the  present  session.  I  shall  recall  one  case  of 
uraemia  which,  although  only  a  short  time  under  observation, 
must  have  interested  those  of  you  who  saw  it. 

Mrs.  K.,  aged  forty-eight  years,  was  admitted  to  Alexandra 
Ward  on  12  th  April,  and  died  on  the  following  day.  She 
suffered  both  from  cirrhotic  and  waxy  disease  of  the  kidney. 
She  had  had  phthisis  for  three  years,  but  had  been  much 
worse  since  October.  She  went  about,  however,  till  the 
beginning  of  March.  For  sixteen  days  before  her  admis- 
sion the  bowels  were  not  moved,  and  there  had  been 
bilious  vomiting  for  a  week.  An  enema  was  then  admini- 
stered, and  it  brought  away  a  large  amount  of  fseculent 
material.  She  also  vomited  a  blackish-red  fluid,  and  a  simi- 
lar fluid  was  passed  by  the  bowel.  There  was  therefore 
probably  some  haemorrhage  in  the  gastro-intestinal  tract. 
She  began  to  have  fits  the  night  before  admission,  and  she 
had  five  altogether  before  she  was  brought  to  the  Infirmary. 
During  the  fits  the  eyes  were  fixed,  the  teeth  were  clenched, 
the  tongue  was  bitten,  the  legs  were  rigid,  and  the  hands 
twitched.      She  remained  unconscious  for  about  half-an-hour 


102  ALBUMINURIA. 

after  the  convulsions  ceased.  When  examined  on  admission 
she  was  delirious,  and  in  a  drowsy  condition,  breathing 
rather  rapidly.  There  was  some  twitching  occasionally  at 
the  angle  of  her  mouth.  The  face  was  flushed,  and  the 
breath  had  a  peculiar  odour.  Physical  examination  revealed 
nothing  additional  with  regard  to  the  alimentary  or  hasmo- 
poietic  systems.  Although  the  heart  was  not  much  enlarged, 
the  first  sound  was  loud  and  thumping,  and  the  second  was 
accentuated.  The  pulse  rate  was  92  per  minute.  It  was 
regular  and  of  high  tension,  and  the  arterial  wall  was 
thickened.  There  were  distinct  signs  of  phthisis  at  both 
apices.  The  breathing  was  24  per  minute,  regular,  but 
laboured.  There  was  slight  oedema  over  the  tibiae.  The 
urine,  which  had  to  be  drawn  off  by  the  catheter,  was  of 
low  specific  gravity  (1009-1012),  and  highly  albumin- 
ous. Microscopically  there  were  a  few  fragments  of 
granular  and  fatty  casts.  The  sensibility  to  touch  and 
pain  appeared  little  affected.  The  pupils  were  equal  and 
moderately  contracted,  and  they  reacted  to  light.  The  move- 
ments of  the  eyeballs  were  natural.  She  was  certainly  blind 
in  one  eye,  and  probably  in  both.  There  was  no  plantar 
reflex.  The  patellar  reflex  was  present  in  both  legs.  Ankle 
clonus  was  present  in  the  right  leg,  and  to  a  less  degree  in 
the  left.  The  contractions  were  slow,  but  well  marked  and 
regular.  The  motor  power  was  undiminished,  but  any  effort 
was  accompanied  with  tremors.  She  was  markedly  delirious, 
and  had  hallucinations  of  sight.  The  treatment  consisted  in 
the  use  of  vapour  baths,  the  application  of  hot  bottles,  and 
the  administration  of  full  doses  of  digitalis. 

At  10.30  p.m.  she  had  another  fit.  She  became  cyanotic, 
and  there  was  twitching,  first  of  the  left  and  then  of  the 
right  side  of  the  mouth,  and  then  violent  general  convul- 
sions. The  tongue  was  bitten,  the  eyes  were  fixed  and 
staring,  and  the   pupils  dilated.      As   the   convulsions   sub- 


URAEMIA.  103 

sided  the  pupils  again  became  contracted,  and  then  dilated 
slowly.  The  breathing  was  stertorous  but  not  rapid.  The 
pulse,  98  per  minute,  was  less  hard  than  before,  but  the 
heart  was  thumping  violently.  There  was  still  some 
twitching  at  the  corners  of  the  mouth.  Three-quarters 
of  an  hour  after  the  fit  she  was  moving  her  arms 
actively,  shouting  and  speaking.  The  pupils  were  more 
dilated.  The  legs  were  cold.  The  ankle  clonus  was  marked. 
She  continued  violent  for  some  time.  The  twitchings  and 
tremor  persisted,  and  the  breathing  was  at  times  laboured 
and  dyspnceic.  She  was  still  in  a  semi-conscious  state.  This 
condition  persisted  till  3  a.m.  She  then  slept  from  3.15 
to  6.40  a.m.,  except  during  occasional  fits  of  dyspnoea^ 
and  while  asleep  no  twitching  was  noticed.  She  awoke  much 
stronger,  sat  up  in  bed,  and  answered  questions  more  ration- 
ally, although  the  tremors  and  nervous  jerkings  were  still 
sufficiently  obvious.  The  pulse  rate  was  88  per  minute,  with 
the  tension  as  before.  The  respiration,  30  per  minute,  was 
short  and  puffing.  She  continued  in  much  the  same  condi- 
tion till  4.45  p.m.,  convulsions  not  recurring,  but  the  respira- 
tion becoming  steadily  more  embarrassed,  and  fluid  accumu- 
lating in  the  bronchi  and  towards  the  bases  of  the  lungs. 
The  breathing  was  40  per  minute.  The  heart  continued 
much  as  before,  but  the  sounds  gradually  became  obscured 
by  mucous  and  snoring  rales.  The  pulse,  86  per  minute, 
was  not  quite  regular.  The  condition  became  gradually 
worse,  and  the  patient  died  that  evening. 

The  post  -  mortem  examination  revealed  the  following 
conditions : — There  was  slight  hypertrophy  of  the  heart, 
but  the  valves  were  competent.  There  were  milk  spots  in 
front  of  the  right  auricle,  and  a  small  patch  of  pericardial 
thickening  near  the  base  of  the  left  ventricle.  The  left  lung 
was  completely,  and  the  right  lung  partially,  adherent  to 
the  chest  wall.      The  left  lung  showed  a  large   amount   of 


104  ALBUMINURIA. 

tubercular  deposit,  and  there  was  an  old-standing  cavity 
occupying  about  a  third  of  the  upper  lobe.  The  right  lung 
was  also  tubercular,  but  to  a  less  extent.  The  bases  were 
congested.  Patches  of  pulmonary  apoplexy  were  scattered 
through  both  lungs.  The  bronchi  contained  much  mucus, 
were  deeply  congested,  and  of  purple  colour.  The  liver 
showed  syphilitic  cicatrices,  and  was  adherent  to  the 
diaphragm.  It  was  cirrhotic  and  waxy,  and  weighed  2  lbs. 
4  \  oz.  The  kidneys  were  large,  the  right  weighing  9 
ounces,  and  the  left  8  ounces.  Their  consistence  was  much 
increased,  the  capsule  was  little  adherent,  but  the  fibrous 
tissue  was  torn  on  stripping.  The  surface  was  uneven.  In 
the  left  kidney  the  surface  had  a  mottled  appearance  (dirty 
greyish -white).  There  were  patches  of  semi -translucent, 
gelatinous  tissue,  surrounded  by  opaque  white  bands.  The 
stellate  vessels  were  here  and  there  distended,  and  so 
were  the  interlobular  vessels.  On  section,  the  cortex  was 
found  to  be  diminished,  and  showed  cirrhotic  and  waxy 
changes.  The  superficial  cortex  measured  scarcely  a 
quarter  of  an  inch,  and  was  of  a  pale,  dirty-grey  colour. 
The  glomeruli  were  not  specially  enlarged.  The  pyra- 
midal portion  was  enlarged  —  measuring  one  inch  from 
apex  to  base — and  had  a  striated,  rosy  colour,  the  vessels 
markedly  waxy.  The  walls  of  the  renal  arterioles 
were  slightly  thickened.  The  right  kidney  was  in  a  very 
similar  condition,  but  there  was  perhaps  more  fatty  change 
in  the  cortex,  which  was  not  so  small  as  in  the  other.  The 
spleen  weighed  4|  ounces.  It  also  showed  the  waxy  change, 
and  there  was  a  fibrous  adhesion  at  one  extremity  from  peri- 
splenitis. The  skull-cap  was  thick,  and  there  was  no  diploe. 
There  was  no  erosion  of  the  inner  surface,  though  the 
grooves  for  the  meningeal  arteries  were  unusually  deep.  The 
meningeal  arteries  were  thickened,  and  at  one  or  two  points 
there  were  small  peri-arterial  nodules.     There  was  some  con- 


UILEMIA.  105 

gestion  of  the  small  venules  on  the  surface,  and  there  was 
cedema  of  the  pia  mater,  especially  over  the  parietal  lobes. 
The  surface  of  the  brain  was  otherwise  aneemic.  The  arteries 
and  membranes  at  the  base  seemed  normal.  On  section, 
the  brain  (both  grey  and  white  matter)  was  very  anaemic  > 
and  slightly  oedematous.  The  lateral  ventricles  showed  no 
increase  of  fluid,  but  slight  congestion  of  the  choroid  plexus 
and  velum  interpositum.  There  was  marked  anaemia  of  the 
grey  matter  of  the  basal  ganglia. 

You  had  thus  the  opportunity  of  witnessing  the  clinical 
features  and  the  post-mortem  appearances  in  a  well-marked 
case  of  uraemia,  and  you  observe  that  no  change  was  present 
except  anaemia  and  some  degree  of  oedema. 

I  do  not  intend  at  present  to  discuss  with  you  the  causes 
of  these  uraemic  symptoms,  and  shall  only  express  the  con- 
clusion to  which  I  have  come.  I  believe  that  in  some  cases 
they  are  due  to  poisoning  of  the  nerve  centres  with  excremen- 
titious  matters  which  the  kidneys  have  failed  to  eliminate, 
that  in  others  they  are  due  to  cerebral  anaemia,  either  from 
vascular  spasm,  or  as  a  mechanical  result  of  serous  effusion 
within  the  cranium,  and  that  sometimes  they  result  from 
organic  alterations  of  the  brain  tissue  of  the  nature  of 
degeneration,  minute  haemorrhages  or  softening  processes. 

Uraemia  occurs  frequently  in  nephritis,  and  that  at  any 
stage  of  the  process.  I  have  shown  you  a  patient  whose  life 
had  been  endangered  by  it  during  the  early  stage,  and  have 
told  you  of  instances  in  which  it  proved  fatal  after  the 
malady  was  far  advanced.  The  later  stages  are  more  apt  to 
be  attended  by  the  chronic  variety,  but  the  acute  is  even 
then  not  of  very  rare  occurrence. 

Waxy  kidney  is  much  less  liable  to  uraemic  complications. 
In  pure  cases  it  is  very  rare  indeed.  In  those  which  are  in 
jjart  waxy  and  in  part  cirrhotic  or  inflammatory  it  is  rela- 
tively more  common. 


106  ALBUMINURIA. 

We  proceed  now  to  consider  another  set  of  nervous 
symptoms  :  the  paralyses  which  are  so  common  in  Bright's 
disease.  Such  symptoms  are,  in  some  cases,  due  to  embolism 
from  the  cardiac  valvular  lesions  or  endarteritis,  in  others  to 
thrombosis  of  cerebral  vessels,  but  oftenest  to  cerebral 
haemorrhage,  the  result  of  the  powerful  action  of  the  hyper- 
trophied  heart,  the  high  vascular  tension,  and  the  degenera- 
tion of  the  vessel  walls.  Sometimes  a  renal  case  terminates 
with  appalling  suddenness  by  haernorrhagic  apoplexy. 

A  patient  of  mine  in  the  Old  Infirmary  was  well-known  to 
successive  classes  of  students  as  illustrating  chronic  inflam- 
matory Bright's  disease.  His  life  had  been  endangered  in 
various  ways  in  the  course  of  his  illness,  but  he  had  on  the 
whole  improved ;  dropsy  had  disappeared,  the  ursemic 
tendency  was  in  abeyance,  and  but  for  the  cardiac  hyper- 
trophy, the  tension  of  pulse,  the  pallor,  and  the  persistent 
albuminuria,  the  patient  seemed  fairly  well.  But  suddenly 
he  was  seized  during  the  night  with  convulsions  and  loss  of 
consciousness.  When  he  was  examined  it  was  concluded 
that  he  was  not  suffering  merely  from  uraemia,  but  that 
haemorrhage  had  occurred.  The  grounds  for  this  opinion 
were  :  the  profound  nature  of  the  coma,  no  noise  or 
pinching  of  the  patient  sufficing  to  rouse  him,  as  might 
probably  have  been  the  case  in  uraemia  ;  the  deep  snoring 
respiration  contrasting  with  the  sharper  or  more  hissing 
sound  produced  by  the  rush  of  the  expired  air  upon  the  hard 
palate  or  teeth,  so  characteristic  of  uraemia  ;  the  complete 
paralysis  of  the  limbs  on  one  side,  so  that  the  one  hand, 
when  lifted  from  the  bed,  fell  like  that  of  a  dead  person, 
while  the  other  was  comparatively  less  flaccid.  These  indi- 
cations, and  especially  the  last,  justify  a  diagnosis  of  haemor- 
rhagic  apoplexy  rather  than  of  uraemia.  Sometimes  the 
existence  of  bilateral  paralysis  from  haemorrhage  into  the 
pons     or     into     both     hemispheres     deprives     us     of    the 


PARALYTIC    SYMPTOMS.  107 

information  to  be  obtained  by  comparing  the  condition  of 
the  two  sides  of  the  body,  but  if  so,  one  generally  finds,  in 
the  case  of  the  pons,  special  paralytic  features,  and  there  are 
always  the  other  symptoms  to  fall  back  upon.  In  the  course 
of  a  few  hours  a  fatal  result  ensued,  and  the  autopsy  showed 
extensive  haemorrhage  in  one  hemisphere  in  the  region  of  the 
basal  ganglia  and  internal  capsule. 

But  a  fatal  result  is  by  no  means  the  rule  in  paralysis 
associated  with  Bright's  disease.  You  will  often  meet  with 
cases  in  which  transient  attacks  occur  and  leave  no  trace 
behind.  I  have  already  told  you  of  a  gentleman  who  had 
only  slight  renal  symptoms,  but  was  seized  with  a  paralytic 
attack  of  the  kind  to  which  I  now  allude.  On  awaking 
one  morning  his  attendant  remarked  that  his  face  was  drawn 
to  one  side,  and  he  complained  of  difficulty  in  speaking  and 
in  raising  his  right  arm.  When  I  saw  him  some  hours  later 
the  facial  paralysis  was  distinct,  there  was  an  unmistakable 
degree  of  aphasia,  and  both  sensibility  and  motion  were 
impaired  in  the  right  arm.  But  within  twenty-four  hours 
the  sensibility  was  restored,  the  speech  a  little  better,  and 
within  a  week  the  hand  recovered  motor  power,  although,  the 
face  remained  slightly  distorted  for  a  longer  period.  Whether 
the  process  was  embolic  or  the  result  of  a  slight  haemorrhage, 
I  cannot  tell  ;  at  all  events,  recovery  was  ere  long  complete, 
and  there  has  been  no  recurrence  of  serious  nervous 
symptoms  during  the  years  that  have  since  elapsed. 

Another  instance  of  a  similar  kind  rises  to  my  recollection. 
A  friend  of  mine,  an  active  business  man  and  zealous  poli- 
tician, had  gone  to  the  north  of  Scotland  on  the  rising  of  parlia- 
ment some  years  ago.  His  health  was  supposed  to  be  quite 
satisfactory.  When  about  to  drive  out  one  day,  his  speech 
became  indistinct,  he  felt  some  weakness  in  the  right  arm, 
and  the  expression  of  his  face  became  altered.  With  the 
help  of  those  about  him  he  got  back  into  the  house,  and 


108  ALBUMINURIA. 

although  he  did  not  lose  consciousness,  he  became  distinctly 
paralysed  on  the  right  side,  especially  in  the  right  arm  and 
the  face,  and  he  lost  the  power  of  speech.  This  probably 
resulted  from  embolism  ;  but,  at  all  events,  gave  the  first 
indication  of  the  existence  of  renal  cirrhosis,  which  must, 
however,  have  been  insidiously  advancing  through  a  period  of 
years.  Neither  the  slight  aphasia  nor  the  paralysis  lasted 
long.  He  rallied  speedily,  and  never  during  the  ten  or 
eleven  months  which  he  survived  did  any  paralytic  symptom 
recur. 

But  these  slighter  attacks  may  be  better  impressed  upon 
your  memories  if  I  show  you  this  patient,  W.  H.,  who  has 
been  for  months  under  our  observation,  and  has  recently  had 
a  slight  paralytic  seizure.  You  know  that  he  has  renal  cirr- 
hosis, complicated  with  considerable  inflammation  of  the  tub- 
ules, that  he  has  had  so  much  dropsy  as  to  require  frequent 
tapping,  and  that  certain  scars  on  his  legs  and  other  indica- 
tions have  led  us  to  suppose  that  waxy  degeneration  of  the 
kidneys  is  not  improbable.  He  was  suddenly  seized  four 
days  ago  with  a  feeling  of  uneasiness  in  the  face,  particularly 
the  mouth  and  the  tongue,  and  he  found  that  his  speech  had 
become  indistinct.  On  examination  we  found  his  mouth 
somewhat  drawn  to  the  left  side,  indicating  a  paralysis  on  the 
right ;  the  naso-labial  fold  was  indistinct  ;  he  was  unable  to 
whistle,  or  to  show  his  teeth,  and  his  tongue  when  protruded 
was  pushed  over  to  the  right  side.  But  there  was  no  differ- 
ence perceptible  in  the  eyelids  nor  in  the  forehead.  There 
was  thickness  of  speech,  but  no  true  aphasia,  and  no  paraly- 
sis of  arm  or  leg.  This  kind  of  facial  paralysis  contrasts  with 
that  due  to  lesion  of  the  nerve,  in  respect  that  the  muscles 
of  the  upper  part  of  the  face  are  unaffected,  and  there  is  none 
of  the  staring  due  to  paralysis  of  the  orbicularis  palpebrarum. 
It  thus  corresponds  to  the  facial  paralysis  in  ordinary  hemi- 
plegia, and  is,  I  have  no  doubt,  due  to  slight  haemorrhage 


PARALYTIC    SYMPTOMS.  109 

involving  certain  fibres  in  the  internal  capsule  or  the  corona 
radiata.  Already  I  see  some  improvement  taking  place  in 
this  patient's  condition,  and  I  hope  that  if,  by  our  repeated 
tappings  and  other  treatment,  we  are  able  to  keep  him  alive 
for  another  month,  you  will  see  the  paralytic  symptoms 
entirely  disappear. 

You  perceive  from  what  I  have  already  said  that  these 
paralytic  complications  occur  in  nephritis  as  well  as  in  cirr- 
hosis, but  they  are  less  common  in  it  than  in  the  other  dis- 
ease, and  in  the  early  stages  are  quite  exceptional ;  it  is  only 
when  a  stage  of  atrophy  has  been  reached  that  you  need 
expect  to  meet  with  them.  In  uncomplicated  waxy  disease 
they  are  of  the  rarest  occurrence,  indeed,  I  may  say  that 
practically  they  are  not  met  with. 

Let  me  recall  to  you  a  case  which  we  recently  studied  at 
the  bedside,  and  which  illustrates  more  than  one  of  the 
special  features  characteristic  of  the  nervous  complications  of 
Bright' s  disease.  The  case  is  that  of  a  man,  A.  C,  aged 
65  years,  a  maker  of  gas-meter  indices,  who,  when  he  came 
under  my  observation,  had  been  the  subject  of  cirrhosis  of 
the  kidney  for  at  least  eighteen  months,  and  probably  much 
longer.  He  told  us  that  his  parents  did  not  live  beyond 
middle  life,  but  he  did  not  know  the  cause  of  their  death ; 
that  at  least  one  brother  had  died  of  phthisis ;  that  he  himself 
had  been  a  temperate  man,  and  had  had  a  comfortable  home 
and  good  food.  He  had  enjoyed  good  health  till  he  was 
nearly  sixty,  but  then  he  began  to  suffer  occasionally  from  pains 
in  the  head,  and  his  health  deteriorated  in  other  respects  ; 
frequent  nocturnal  micturition,  and  other  symptoms,  giving 
indication  that  renal  cirrhosis  was  establishing  itself.  About 
eight  months  before  his  admission  to  the  Infirmary,  he  had 
been  irritable  and  out  of  sorts  for  some  days,  and  then  one 
day,  while  walking  on  the  shore  at  Portobello,  he  fell  several 
times  owing  to  slight  paralysis,  unattended  by  loss  of  con- 


110  ALBUMINURIA. 

sciousness.  He  was  able  to  pick  himself  up  each  time  with 
a  little  assistance,  but  got  home  with  great  difficulty.  From 
this  time  his  power  of  walking  and  of  using  his  hand  was 
much  impaired,  his  intelligence  became  dull,  and  he  lost  his 
memory  very  rapidly.  His  eyesight  also  became  affected. 
Two  months  later  he  had  a  pretty  severe  epistaxis.  Four 
months  before  admission  he  had  a  second  attack  of  paralysis, 
this  time  affecting  the  left  arm  and  leg  and  the  right  side  of 
the  face.  The  arm  and  leg  soon  recovered,  but  the  right 
side  of  the  face  continued  paralysed.  His  speech  had  since 
then  been  less  distinct  than  formerly,  but  there  did  not 
appear  to  have  been  any  actual  aphasia. 

When  he  was  admitted  to  the  Infirmary  there  was  no 
dropsy,  the  paralysis  on  the  right  side  of  the  face  was  still 
present,  and  there  was  also  some  drooping  of  the  left  eyelid. 
There  was  some  muscular  twitching  about  the  mouth.  The 
temporal  arteries  were  prominent  and  very  tortuous.  The 
tongue  was  furred  and  fissured,  but  the  appetite  was  good. 
Examination  of  the  abdomen  revealed  nothing  abnormal. 
Both  the  heart  sounds  were  reduplicated,  the  first  had  a 
slapping  character,  in  the  aortic  area  the  second  was  accent- 
uated, while  in  the  mitral  area  a  faint  systolic  murmur 
was  sometimes  heard.  The  condition  apparently  was  one  in 
which  hypertrophy  had  been  followed  by  degeneration  of  the 
muscular  wall.  The  pulse  rate  was  94  per  minute.  The 
vessel  was  very  tense,  and  its  wall  was  much  thickened  and 
tortuous.  The  lungs  showed  no  important  change.  The 
urine  was  pale  and  of  low  specific  gravity  (1016),  of  acid 
reaction,  and  contained  albumen  which,  when  estimated  by 
Esbach's  method,  amounted  to  2*8  grammes  per  litre.  A 
trace  of  peptone  was  also  present.  The  urea  amounted  to 
307  grains  in  the  twenty-four  hours.  Microscopically  there 
were  squamous  epithelial  cells  and  some  granular  matter, 
but  no  distinct  casts.     As  to  the  condition  of  the  nervous 


PARALYTIC    SYMPTOMS.  Ill 

system,  examination  of  the  sensibility  was  difficult,  owing  to 
the  mental  condition,  but  no  distinct  abnormality  was  made 
out.  There  was  a  diminution  in  the  field  of  vision,  and  con- 
siderable impairment  of  sight,  and  the  fundus  was  hazy  and 
the  disc  hyperaemic.  Accommodation  was  deficient.  The 
plantar  reflex  was  well  marked,  and  the  patellar  reflex  was 
present  on  both  sides.  There  was  no  ankle  clonus.  Volun- 
tary movements  were  interfered  with  by  the  weakness  and 
tremor  of  the  limbs,  but  co-ordination  was  not  otherwise 
affected.  His  power  of  attention,  memory,  and  intelligence, 
were  much  impaired.     There  was  no  actual  aphasia. 

After  being  in  the  Infirmary  for  nearly  a  month,  during 
most  of  which  he  was  in  a  sort  of  torpid  condition,  the 
patient  passed  into  a  state  of  more  marked  uraemia,  becom- 
ing drowsy,  stupid,  and  ultimately  comatose,  with  muscular 
twitchings,  moderately  dilated  pupils  (the  left  more  than 
the  right),  and  long-drawn  somewhat  stertorous  breathing, 
evidently  dyspnoea  of  the  form  which  I  have  already  de- 
scribed as  uraemic,  the  result  of  the  toxic  action  of  the  blood 
on  the  respiratory  centres.  There  was  also  slight  external 
strabismus.  Gradually  the  coma  became  more  profound, 
and  he  died. 

On  post-mortem  examination  there  was  no  subcutaneous 
oedema.  There  was  senile  atrophy  of  the  brain  with  gelatin- 
ous fluid  in  the  arachnoid  space.  The  grey  matter  of  the 
hemispheres  was  atrophied,  the  white  matter  of  the  centrum 
ovale  was  very  oedematous.  The  cortical  part  of  both  occipital 
lobes  contained  several  old  haemorrhages,  each  of  about  the 
size  of  a  pea.  The  vessels  at  the  base  of  the  brain  were 
atheromatous  and  there  were  miliary  aneurisms  in  the  occi- 
pital lobe,  but  not  elsewhere,  as  far  as  was  ascertained.  The 
heart  was  hypertrophied  and  slightly  fatty.  The  valves  were 
competent.  There  were  old  pleuritic  adhesions.  There  was 
emphysema  at  the  apices  of  the  lungs  and  hypostatic  con- 


112  ALBUMINURIA. 

gestion  at  the  bases.  The  kidneys  were  in  an  advanced 
state  of  cirrhosis — the  left  weighing  2\  ounces — the  right 
2  ounces.  The  cortex  was  much  atrophied,  and  contained 
numerous  small  cysts  and  capillary  haemorrhages.  There 
were  old  adhesions  about  the  liver  and  spleen. 

Taking  together  the  clinical  history  and  the  anatomical 
conditions,  the  interest  attaching  to  this  case  is  considerable. 
The  nervous  symptoms  consisted  in  dimness  and  narrowing 
of  the  field  of  vision,  a  degree  of  paralysis  localised  in  differ- 
ent parts  and  at  different  times  during  the  last  eight  months 
of  life,  general  torpor  and  hebetude,  passing  ultimately  into 
coma.  The  dimness  of  sight  I  expected  at  first  to  find 
explained  by  retinal  changes,  but  on  ophthalmoscopic  exami- 
nation it  turned  out  that  there  was  no  albuminuric  retinitis 
but  simply  hyperemia  of  the  disc,  with  slight  haziness  of  the 
fundus  generally.  But  when  the  autopsy  revealed  haemor- 
rhages in  the  occipital  lobes,  it  was  clear  that  the  amblyopia 
might  very  probably  have  been  central.  As  to  the  paralytic 
seizures,  it  seemed  possible  that  the  stumbling  and  falling, 
with  temporary  recovery,  resulted  from  these  haemorrhages,  for 
one  can  understand  how  such  accidents  occurring  in  the 
visual  centre  might  interfere  with  equilibration,  but  this  could 
not  explain  all  the  paralytic  symptoms,  and  it  is  possible  that 
embolic  or  thrombic  processes  may  have  occurred  in  connec- 
tion with  the  vessels  in  the  motor  cortex  or  tracts.  Certainly 
the  post-mortem  examination  did  not  reveal  traces  of 
haemorrhages  in  these  regions.  The  decay  of  intelligence 
and  gradually  deepening  torpor  was  explained  during 
life,  you  will  remember,  as  suggesting  to  my  mind  what 
I  have  been  in  the  habit  of  calling  uraemia  with  organic 
change,  and  the  degenerative  alterations  revealed  at  the 
autopsy  confirmed  this  view.  The  state  of  the  kidneys 
was  extremely  characteristic  of  advanced  cirrhosis,  and 
the    nervous   symptoms   and    lesions    afforded    examples    of 


CEREBRAL    HEMORRHAGE    IN    RENAL    DISEASE.  113 

more     than     one    of    the    nervous     complications     of    the 
malady. 

I  should  like  to  impress  upon  you  four  points  in  relation 
to  such  haemorrhage  in  cirrhotic  and  other  chronic  forms 
of  Bright's  disease.  The  first  is,  that  patients  with  these 
diseases  are,  for  the  reasons  which  I  have  already  stated, 
exceedingly  liable  to  cerebral  haemorrhage.  It  is  therefore 
very  important  in  every  case  of  cerebral  haemorrhage  to 
which  you  are  called,  to  satisfy  yourselves  not  only  as  to 
the  state  of  the  nervous  system,  the  heart  and  vessels,  but 
also  as  to  the  kidneys,  and  in  your  management  of  cases 
of  renal  disease,  it  is  necessary  to  bear  these  risks  in  mind. 
The  second  point  is,  that  cerebral  haemorrhage  occurring  in 
this  disease  sometimes  proves  very  rapidly  fatal — much  more 
so  than  in  cases  without  Bright's  disease.  The  third  point 
is,  that  slight  and  passing  paralyses  are  common  in  chronic 
renal  cases.  The  fourth  is,  that  sometimes  the  coexistence 
of  other  nervous  symptoms  with  those  proper  to  haemorrhage 
makes  the  illness  appear  more  formidable  than  the  lesion 
would  warrant,  and  so  unexpected  improvement  sometimes 
occurs.  In  fact,  when  I  am  called  to  a  case  of  cerebral 
haemorrhage  in  which  the  condition  seems  almost  hopeless,  I 
am  rather  comforted  than  otherwise  if  I  find  that  it  is  com- 
plicating a  renal  lesion. 


LECTURE    IX. 

ALBUMINURIA  FROM  WAXY  OR  AMYLOID  DEGENERA- 
TION OF  THE  KIDNEY. 

Case  of  Waxy  Disease  in  Early  Stage, — Grounds  for  the  Diagnosis. 
— C  •usal  Complications. — Concomitant  Complications. — Poly- 
uria.— Termination  of  Case. — Autopsy. — Modes  of  Termination 
of  the  Disease. — Stages  of  the  Process. — Explanation  of  the 
Albuminuria. 

P\  ENTLEMEN, — I  take  the  opportunity  to-day  of  drawing 

your  attention  to  a  pure  example  of  waxy  or  amyloid 

disease    of   the    kidneys,    from    which    those    of    you    who 

attended  my  wards  last  summer  have  already  learned  some 

useful   lessons.      The  case  was  that   of    the  patient  A.  D., 

who  came  in  on   27th  May,  1886,  suffering  from  polyuria. 

His  urine  was  of  very  low  specific  gravity — as  a  rule,  about 

1005,  or  even  lower,  and  at  the  time  of  his  admission  was 

free  from   albumen.      The  case  looked  at  first  like  one  of 

diabetes  insipidus,  but  very  shortly  after  his   admission   it 

was  found  that,  though  cold  nitric  acid  continued  to  give 

no  perceptible  reaction,  some  of  the  more  delicate  tests  did 

give  a  slight  opacity  indicative  of  albumen.      After  a  time  a 

very  faint  cloud  was  produced  by  nitric  acid,  and  gradually, 

but   steadily,    the   albumen   increased.      Here,  then,  we  had 

polyuria  with  slight  albuminuria,  and  the  case  was  on   that 

account  suspected  to  be  one  of  waxy  kidney.     But   there 

was    no     apparent    cause    of    waxy    disease,    and    in    the 

absence  of  that  kind  of  evidence,  there  was  some  hesitation 
114 


WAXY    DISEASE.  115 

about  the  diagnosis.  True,  he  had  had  chronic  suppuration 
once,  of  which  he  still  showed  tokens  in  old  cicatrices  on 
the  right  side  of  the  chest,  but  this  suppuration  had 
entirely  ceased  eight  years  before,  and  it  seemed  impossible 
for  a  suppurative  process  so  long  past  now  to  set  up 
waxy  degeneration.  But  when  my  resident  physician,  Dr. 
Simpson,  was  examining  him  quietly  one  evening,  he 
detected  a  degree  of  fulness  and  undue  resistance  in  the 
region  of  the  right  kidney,  and,  when  asked  about  it,  the 
patient  admitted  that  he  had  for  some  time  felt  pain  in  that 
neighbourhood.  Shortly  afterwards  a  somewhat  elastic 
swelling  appeared  a  little  below  Poupart's  ligament,  and 
fluctuation  between  this  and  the  swelling  in  the  region  of 
the  kidney  gradually  became  perceptible.  It  was  thus  clear 
that  an  abdominal  abscess  of  very  considerable  size  existed, 
that  it  had  been  insidiously  advancing,  probably  for  a 
very  considerable  time,  and  thus  the  missing  link  of 
evidence  was  supplied.  We  had  a  sufficient  cause  of  waxy 
kidney. 

As  regards  the  urine,  the  quantity  was  large.  On  the  day 
after  his  admission  it  measured  100  ounces,  about  ten 
days  later  it  had  risen  to  200,  on  the  2nd  July  it  measured 
270  ounces.  As  I  have  told  you,  it  gave  no  reaction  for 
albumen  at  the  time  of  admission.  A  few  days  afterwards, 
however,  picric  acid  showed  a  trace  ;  and  about  ten  days 
later  nitric  acid  began  to  show  it.  We  made  a  considerable 
series  of  quantitative  estimations  of  the  albumen  by  various 
methods,  and  found  that  it  underwent  a  steady  increase. 
On  27th  June  it  had  reached  017  per  cent.,  as  estimated 
by  Esbach's  method  ;  on  6th  August  it  reached  0  32  per 
cent. ;  and  on  9th  August,  0-6  per  cent.  The  urea  in  24 
hours  amounted  on  29th  May  to  518  grains;  after  this  it 
underwent  a  gradual  diminution,  till  on  10th  June  it 
amounted  to  only  307  grains.      Peptones  although  absent  at 


116  ALBUM  INUKIA. 

first,  were  detected  on  23rd  June,  and  from  that  time  their 
amount  increased. 

The  question  has  been  asked  whether  there  is  anything  in 
the  form  of  albumen  present  diagnostic  of  waxy  disease.  A 
number  of  years  ago  Senator (20)  stated  that  in  cases  of  waxy 
kidney  serum-globulin  was  more  abundant  in  the  urine  than 
serum-albumen,  and  that  waxy  Bright's  disease  could  thereby 
be  diagnosed.  This  statement,  however,  has  not  been  con- 
firmed by  others.  In  the  present  case  a  quantitative  estima- 
tion of  these  two  forms  of  albumen  was  made  by  separating 
them,  by  neutralising  the  urine,  and  saturating  it  with 
sulphate  of  magnesia.  The  estimation  was  then  made  by 
Sir  William  Roberts's  dilution  method.  It  was  found  that 
there  were  50  degrees  of  serum-albumen  present,  and  20 
degrees  of  serum-globulin.  The  serum-albumen  was  there- 
fore in  much  larger  proportion  than  serum-globulin.  I 
would  therefore  have  you  believe  that  there  is  evidence 
quite  sufficient  to  rebut  the  statement  of  Senator  to  which  I 
have  referred. 

What,  then,  were  the  grounds  for  diagnosis  in  this  case  ? 
These  I  shall  give  you  under  three  heads : — 

In  the  first  place,  we  had  the  existence  of  a  causal  com- 
plication. As  I  have  told  you,  the  patient  had,  eight  years 
before,  suffered  from  suppuration  on  the  right  side  of  the 
chest,  most  probably  due  either  to  bone  disease  or  empyema. 
He  also  had  an  abscess  on  the  back  of  the  right  thigh.  But 
these  would  not  have  sufficed  for  our  purpose  unless  we 
had  also  found  evidence  of  the  more  recent  and  still  existing 
suppuration.  Every  one  who  has  written  on  Waxy  Disease 
has  admitted  the  importance  of  this  as  a  point  in  diagnosis. 
We  look,  in  all  cases  of  suspected  degeneration,  for  the 
presence  of,  or  at  least  a  history  of,  some  chronic  wasting 
disease,  such  as  syphilis,  prolonged  suppuration,  disease  of 
bone,  or  phthisis. 


POLYURIA    IN    WAXY    DISEASE.  117 

The  second  ground  for  diagnosis  of  waxy  disease  is 
the  existence  of  concomitant  complications — the  presence  of 
waxy  disease  in  other  organs.  There  was  in  this  case  no 
evidence  of  waxy  liver  or  spleen,  or  of  waxy  disease  of  the 
stomach  or  intestine.  This  kind  of  evidence  was  therefore 
awanting.  There  is  in  regard  to  it,  also,  general  agreement 
amongst  authorities  on  the  subject  ;  but  I  would  advise  you 
not  to  trust  absolutely  to  it.  Ten  or  twelve  years  ago 
Furbringer (74)  published  a  paper  on  waxy  disease,  in  which 
he  gave  the  report  of  the  post-mortem  examination  in  four 
cases  in  which,  a  wrong  diagnosis  was  made  by  over-estimat- 
ing the  importance  of  concomitant  complications,  such  as 
enlarged  liver  and  spleen.  On  the  other  hand,  there  may, 
as  in  the  present  case,  be  no  other  waxy  change,  and  yet 
you  may  correctly,  and  even  in  an  early  stage,  diagnose 
waxy  kidney. 

The  third  ground  of  diagnosis,  and  one  in  which  I  have 
great  confidence,  is  the  existence  of  polyuria.  In  pure  cases 
this  is  always  present,  but  it  is  not  to  be  expected  in 
every  case  in  which  there  is  waxy  disease,  for  its  occurrence 
may  be  prevented  by  complications.  Thus,  the  severe  and 
intractable  diarrhoea  which  results  from  waxy  disease  of 
the  intestine,  and  sometimes  from  tubercular  disease,  drains 
the  system  of  water,  and  necessarily  prevents  the  discharge 
of  a  large  amount  of  fluid  from  the  kidneys.  The  coexist- 
ence of  wide-spread  inflammation  of  the  tubules  along  with 
the  waxy  disease  also  prevents  polyuria.  I  wish  further  to 
impress  upon  you  the  fact  which  this  case  illustrates,  that 
polyuria  may  give  the  clue  to  diagnosis  of  waxy  kidney  even 
before  a  trace  of  albumen  be  detected  in  the  urine.  Of  these 
facts  I  was  able  to  satisfy  myself  many  years  ago  when  first 
making  a  study  of  this  subject. 

There  has  been  a  strange  contrariety  of  opinion  on  the 
subject  of  polyuria  in  waxy  Bright's  disease,  and  I  shall  now 


118  ALBUMINURIA. 

bring  under  your  notice  the  views  of  some  of  the  leading 
authors  who  have  written  upon  it,  and  explain,  as  far  as  that 
is  possible,  how  the  differences  of  opinion  have  arisen :  Dick- 
inson/7^ Rosenstein/70)  Sir  William  Roberts,(16)  Ralfe,(76)  and 
Purdy(77)  concur  in  regarding  it  as  a  characteristic  symptom. 
In  the  first  edition  of  Ziemssen's  "  Cyclopaedia  of  the  Practice 
of  Medicine,"  the  article  on  this  subject  was  written  by 
Professor  Bartels(78)  of  Kiel,  and  he  also  substantially  agreed 
with  the  above-named  authorities.  In  the  second  edition  the 
subject  was  taken  up  by  Professor  Wagner (79)  of  Leipsic,  and 
he  divided  cases  of  waxy  kidney  into  three  groups,  in  relation 
to  the  amount  of  urine.  In  his  first  group  the  urine  presented 
no  peculiarity — was  neither  increased  nor  diminished  in 
quantity,  and  did  not  contain  albumen.  In  the  second  group, 
there  was  an  increased  flow  of  urine,  containing  more  or  less 
albumen.  In  the  third  group,  the  urine  was  diminished  in 
quantity,  and  albumen  was  very  distinctly  present.  These 
three  groups  can,  I  think,  be  easily  explained.  In  the 
first  Wagner  included  every  case  which  exhibited  even  the 
slightest  waxy  degeneration  of  the  vessels  of  the  Malpighian 
tufts  or  of  the  vessels  supplying  the  tubules.  In  such  cases 
the  urine  may  not  be  changed,  either  because  the  waxy 
disease  is  so  slight,  or  because  it  is  not  in  the  right  place  to 
produce  symptoms.  The  state  of  the  urine  in  the  second 
group  of  cases  corresponds  to  what  seems  to  me  typical 
of  waxy  Bright's  disease.  The  small  amount  of  urine  pre- 
sent in  the  third  group  of  cases  appears  to  be  explained  by 
the  waxy  disease  being  complicated  with  inflammation  of  the 
tubules  or  other  disease.  Lecorche,(80)  again,  holds  the 
peculiar  view  that  waxy  disease  is  not  attended  by  albumin- 
uria, but  that  the  albuminuria,  when  it  occurs,  is  due  to 
complication  with  inflammatory  disease  of  the  tubules.  My 
own  observations  do  not  at  all  warrant  such  a  conclusion, 
whether  regarded  in  the  light  of  the  purely  waxy  or  of  the 


POLYURIA    IN    WAXY    DISEASE.  119 

mixed  processes.  Professor  Charcot,(81)  again,  appears  to 
attach  very  little  importance  to  this  symptom.  He  says, 
indeed,  that  in  the  amyloid  disease  there  are  no  symptoms 
directly  characteristic.  I  cannot  but  think  that  if  these 
authors  were  to  watch  pure  instances  of  the  disease  such  as 
we  are  studying  to-day,  they  would  come  to  different  conclu- 
sions, and  take  the  view  broadly  stated  by  Dr.  Murchison,(82) 
that  he  found  in  waxy  cases,  as  a  rule,  an  increased  quantity 
of  urine,  the  patient  voiding  not  uncommonly  from  three  to 
five  pints  in  the  day,  throughout  the  greater  part  of  the 
course  of  the  malady. 

If  one  of  you  were  to  ask  me  in  how  far  I  had  found 
polyuria  a  reliable  symptom  of  waxy  disease,  I  should 
answer  that  by  looking  for  it  I  have  again  and  again  made 
out  the  presence  of  waxy  disease  in  cases  in  which  the 
diagnosis  would  otherwise  have  been  missed.  In  a  few  cases 
also  I  have  been  enabled  by  it  to  make  out  the  presence  of 
waxy  disease  before  the  occurrence  of  albuminuria.  I  have 
also  escaped  error  in  a  number  of  cases  in  which  there  was 
enlargement  of  the  liver  and  spleen,  and  in  other  respects 
good  grounds  for  diagnosing  waxy  disease,  by  refusing  to 
commit  myself  to  a  diagnosis,  seeing  that  there  was  neither 
polyuria  at  the  time  nor  a  history  of  its  previous  exist- 
ence. 

The  polyuria  is  not  a  mere  result  of  polydipsia,  for  the 
urine  discharged  is  often  in  excess  of  the  whole  measurable 
liquids  taken  in.  In  many  cases  of  cirrhosis,  and  in  some  of 
inflammation  of  the  tubules,  there  is  also  increased  flow  of 
urine,  but  it  is  only  when  these  diseases  are  well  advanced 
that  the  symptom  arises,  whereas  it  is  the  earliest  renal 
symptom  in  many  waxy  cases. 

As  regards  the  further  history  of  our  patient,  the  abscess 
was  opened  by  Professor  Annandale.  The  drain  of  pus  was 
very  great,  and  the  patient  went  downhill    pretty    rapidly. 


120  ALBUMINURIA. 

Another  abscess  developed,  and  shortly  before  death  there 
appeared  to  be  commencing  suppuration  in  the  region  of  the 
right  hip-joint.  He  died  on  August  13th,  not  from  the 
waxy  disease  but  from  exhaustion  produced  by  the  suppura- 
tion. Unfortunately  we  could  not  get  a  complete  post- 
mortem examination,  but  we  were  able  to  secure  the  kidneys. 
They  were  pale,  and  the  Malpighian  tufts  and  many  of  the 
small  arteries  showed  the  degeneration  very  distinctly. 
There  were  also  slight  traces  of  inflammatory  change  in 
some  of  the  tufts  and  in  patches  of  the  stroma. 

I  have  told  you  that  the  patient  did  not  die  of  the  waxy 
disease,  and  indeed  it  is  not  as  a  rule  the  waxy  disease 
which  kills.  Let  me,  therefore,  explain  the  usual  modes  of 
termination  of  this  malady. 

In  many  cases  the  patients  die  of  other  diseases,  especially 
of  one  or  other  of  the  causal  complications.  Thus  most  of 
you  must  have  seen  patients  die  of  chronic  abscess,  of 
phthisis,  or  of  caries  of  bone,  whose  kidneys  turned  out,  on 
post-mortem  examination,  to  be  waxy. 

Now  and  then  you  will  observe  that  a  superadded  inflam- 
mation of  the  tubules  brings  about  the  fatal  result. 

Sometimes  there  is  slow  advance,  and  ultimately  death  in 
a  more  or  less  distinct  ursemic  condition.  I  have  seen  a  few 
cases  in  which  this  occurred,  without  there  being  much  to 
indicate  the  supervention  of  other  renal  disease. 

There  may  be  a  partial  or  complete  recovery.  If  the 
causal  complication  can  be  removed,  the  kidneys  may 
gradually  improve  and  again  become  sound.  For  upwards 
of  twenty  years  I  have  known  this  fact  both  as  to  the  liver 
and  the  kidneys,  and  my  conviction  has  been  more  firmly 
established  by  the  writings  of  Sir  Dyce  Duckworth (83)  and 
others  on  the  point. 

All  my  experience  tends  to  confirm  the  impression  that 
the  waxy  process  in  the  kidney  passes  through  what  we  may, 


WAXY    DISEASE.  121 

for  convenience  of  description,  call  three  stages.  I  have 
examined  after  death  a  large  number  of  bodies  in  which  the 
kidneys  appeared  almost  natural  to  the  naked  eye,  but  in 
which  the  microscope  and  suitable  colouring  materials  revealed 
evidence  of  the  degeneration.  This  corresponds  to  what  we 
may  term  the  first  stage.  If  the  disease  has  gone  on  for  a 
considerable  period,  say  from  six  months  to  one,  two,  or  three 
years,  the  organs  are  found  large  and  pale,  constituting  one  of 
the  varieties  of  what  is  still  termed,  by  some  writers,  the  large 
white  kidney.  The  waxy  disease  is  in  such  cases  extensively 
distributed  throughout  the  kidneys,  but  in  addition  there  are 
secondary  alterations.  Many  of  the  tubules  are  blocked  by  a 
hyaline  or  colloid  material,  and  the  epithelium  is  extensively 
altered,  sometimes  with  ordinary  inflammatory,  and  some- 
times with  simple  degenerative  processes.  This  transudation 
is  the  cause  of  the  enlargement  and  the  pallor  of  the  organ, 
and  the  condition  corresponds  to  the  second  stage.  In  cases 
which  have  lived  on,  say  for  three  years  or  upwards,  the  organ 
is  found  to  be  more  or  less  diminished  in  bulk,  it  may  be 
only  slightly,  or  to  an  extreme  degree.  If  far  advanced,  the 
kidneys  closely  resemble  those  of  advanced  cirrhosis,  but  they 
differ  in  being  less  fibrous,  in  having  the  Malpighian  bodies 
far  more  prominent,  these  structures  being  preserved  while 
the  surrounding  tubules  are  completely  destroyed,  and  the 
remaining  tubules  are  seen  in  various  stages  of  collapse  con- 
sequent upon  the  absorption  of  their  contents  molecule  by 
molecule.  The  fibrous  stroma  is  relatively,  nay,  is  absolutely 
increased,  but  not  in  the  same  measure  as  in  the  purely 
cirrhotic  process.  This  constitutes  the  third  stage.  Of  the 
correctness  of  this  description  I  have  no  doubt,  and  while  I 
quite  admit  that  interstitial  inflammatory  changes  may  arise, 
and  in  some  cases  mainly  account  for  the  shrinking  of  the 
organ,  it  appears  that  the  intratubular  process  is  the  more 
important  cause. 


122  ALBUMINURIA. 

We  have  next  to  inquire  as  to  the  cause  of  the  albumin- 
uria in  cases  of  waxy  kidney  ? 

May  the  cause  be  in  the  blood  ?  Of  this  we  have  no 
evidence.  It  is  ordinary  serum-albumen  and  globulin  which 
transude,  not  any  special  form  of  albumen,  and  we  know  of 
no  blood  change  whatever  in  cases  of  waxy  kidney  which 
could  have  the  effect  of  producing  albuminuria. 

May  the  cause  be  in  the  blood  pressure  ?  Here  again 
we  have  no  evidence  in  support  of  such  a  view.  There  is 
not  the  hypertrophy  of  the  left  side  of  the  heart  and  the 
thickening  and  tension  of  the  arteries  which  are  present  in 
cirrhotic  Bright's  disease.  In  fact  there  is  no  evidence  of 
any  marked  alteration  of  blood  pressure. 

It  has  been  maintained  that  changes  in  the  epithelium 
of  the  tubules  and  of  the  Malpighian  bodies  may  have  to  do 
with  it.  Undoubtedly,  in  many  cases  there  are  changes  in 
these  parts  owing  to  the  coexistence  of  inflammation,  more 
or  less  extensive,  or  to  degenerative  changes  secondary  to 
the  waxy  degeneration  proper.  In  some  cases  therefore  we 
must  ascribe  waxy  albuminuria  to  these  causes,  but  they  do 
not  afford  the  whole  explanation. 

The  great  cause  of  albuminuria  in  waxy  kidney  is  in 
all  probability  the  alteration  of  the  vessel  walls.  We  know 
that  their  structure  is  markedly  altered,  and  we  can  readily 
understand  that  though  thickened  their  walls  may  have 
become  more  permeable.  We  have,  indeed,  an  analogous 
phenomenon  which  lends  a  measure  of  support  to  this  view. 
In  waxy  disease  of  the  intestine  there  is  profuse  and  per- 
sistent watery  diarrhcea  probably  owing  to  the  excessive 
transudation  from  the  waxy  vessels  ;  and  this  symptom, 
like  the  albuminuria,  finds  a  ready  explanation  in  this 
hypothesis. 


LECTURE    X. 
ON  ALBUMINURIA  FROM  FEVER  AND  OTHER  CAUSES. 

Febrile  Albuminuria. — Statements  of  previous  Observers. — Explana- 
tion of  the  Albuminuria. 

Albuminuria  from  Diseases  of  Circulatory  System.  —  Explana- 
tion. 

Albuminuria  associated  with  Diseases  of  the  Alimentary  System. — 
Explanation. 

Albuminuria  associated  with  Diseases  of  the  Nervous  System. — 
Explanation. 

Albuminuria  with  Glycosuria. 

C\  ENTLEMEN, — Leaving  now  the  consideration  of  the 
forms  of  albuminuria  due  to  renal  conditions  of  vital 
importance,  we  proceed  to  consider  groups  of  cases  in  which 
the  symptom  appears  in  association  with  a  variety  of  morbid 
processes,  does  not  as  a  rule  indicate  serious  disease  of  the 
kidney,  and  is  a  comparatively  unimportant  element  in  the 
morbid  action. 

The  first  group  is  that  of  Febrile  Albuminuria,  under 
which  I  include  all  forms  dependent  upon  elevation  of  tem- 
perature whether  the  process  be  idiopathic  or  symptomatic, 
with  the  exception  of  such  as  are  referable  to  renal  inflam- 
mation or  other  categories.  In  Table  XXL  I  show  you  the 
results     brought    out    in    the    different    groups    of    cases 

examined. 

123 


124 


ALBUMINURIA. 


Table  XXI. — Showing  the  Incidence  op  Albuminuria 

ASSOCIATED    WITH   FEBRILE    CONDITIONS. 


No.  of            "With 
Patients.         HNOg. 

With 
Picric  Acid. 

Total. 

Per  cent. 

Fever  House, 
Private,. 

Indoor  Infirmary,  . 
Outdoor  Infirmary, 
Royal  Hospital  for  Sick 
Children,    . 

50       !       18 
150                1 
150                3 
100                0 

50                2 

15 
0 
2 
0 

1 

33 
1 
5 
0 

3 

66 

You  observe  that  in  the  Fever  House  cases,  33,  or  G6  per 
cent.,  showed  albumen  with  picric  acid  ;  while  1 8  of  these, 
or  36  per  cent,  had  it  in  such  quantity  as  to  show  distinctly 
with  nitric  acid.  The  proportions  thus  correspond  pretty 
closely  to  those  obtained  on  examining  the  old  male  paupers, 
the  soldiers  after  fatigue  duty,  and  the  boys  after  violent 
and  prolonged  exertion.  The  proportion  of  febrile  cases  in 
the  other  groups  was  small,  and  in  a  number  of  these  in 
whom  pyrexia  existed,  the  albuminuria  was  due  to  other 
causes.  Among  the  indoor  hospital  patients,  five  showed 
albumen — two  with  picric,  and  three  with  nitric  acid.  Among 
the  patients  in  the  Sick  Children's  Hospital,  three  showed 
the  symptom — two  with  nitric  acid,  one  only  with  picric. 
Among  the  private  patients,  one  only  showed  it,  and  that 
with  nitric  acid. 

In  giving  these  statistics  I  do  not  in  the  least  assume  that 
they  afford  ground  for  important  conclusions  ;  such  results 
could  only  be  obtained  by  one  who  had  access  to  a  much 
more  extended  series  of  febrile  cases,  and  could  work  out  a 
complete  account  of  the  facts  in  each  variety  of  fever, 
examinations  being  repeated  daily,  or,  still  better,  upon  each 
micturition,  so  as  to  determine  the  precise  incidence  in  each 
variety  and  in  each  stage  of  the  process.  I  am  not  aware 
that  this  has  been  done  more  thoroughly  by  any  observers 


IN    FEVEE.  125 

than  by  Dr.  Stevenson  Thomson,(84)  in  regard  to  scarlet  fever, 
and  Dr.  George  Middleton,(85)  in  regard  to  typhus  and 
typhoid. 

The  former  made  observations  on  180  consecutive  cases  of 
scarlet  fever,  three  specimens  from  each  case  being  examined 
daily  for  a  period  generally  of  about  fifty-six  days.  Accord- 
ing to  the  period  of  its  occurrence  he  distinguishes  between 
initial  and  late  albuminuria,  in  the  former  the  albumen 
being  detected  during  the  first  week,  in  the  latter  not  till 
after  that  time.  He  found  40  examples  of  initial  albumin- 
uria out  of  a  total  of  1 1 2  cases  of  albuminuria  of  all  kinds  in 
180  cases  of  scarlatina.  This  variety  is  not  itself  dangerous 
— only  becoming  so  when  it  passes  into  the  late  albuminuria, 
as  it  did  in  9  out  of  the  40  cases.  In  31  cases  the  initial 
albuminuria  was  speedily  recovered  from,  but  in  21  late 
albuminuria  followed.  Late  albuminuria  may  occur  at  any 
time  from  the  ninth  to  the  forty-eighth  day,  but  has  a 
preference  for  the  beginning  of  the  second,  third,  and  in  a 
less  degree,  the  sixth  week.  Of  the  180  cases,  112  or  63*2 
per  cent,  showed  by  the  presence  of  albumen  or  blood  in  the 
urine  more  or  less  distinct  signs  of  renal  inflammation,  55 
being  cases  of  pure  albuminuria,  and  57  cases  of  hematuria. 
Of  the  latter  some  contained  blood  only,  and  it  was  in  these 
that  he  sometimes  found  what  has  been  called  a  "  pre-albu- 
minuric  stage,"  by  which  is  meant  a  "stage  in  nephritis, 
characterised  by  increased  vascular  tension,  and,  as  a  result, 
the  presence  of  blood  crystalloids  in  the  urine  before  albumen 
makes  its  appearance."  In  some  cases  there  was  dropsy 
without  albuminuria, — albumen  appearing  in  some  of  these 
after  the  dropsy  has  become  manifest. 

His  figures  you  observe  correspond  pretty  closely  to  those 
which  I  obtained  in  the  38  cases  of  scarlet  fever  which  we 
examined  in  the  City  Fever  Hospital.  His  proportion  being 
63*2  and  mine  60-5  3  per  cent,,  but  then  his  results  refer  to 


126  ALBUMINURIA. 

the  whole  process,  while  my  observations  referred  only  to 
the  early  period,  and  corresponded  to  his  initial  variety  only. 
I  believe  that  the  incidence  of  albuminuria  in  scarlet  fever 
varies  greatly  in  different  epidemics,  apart  altogether  from 
the  surroundings  of  the  patients. 

Dr.  Middleton  reported  that  he  had  examined  a  series  of 
30  cases  of  typhoid  and  27  of  typhus  as  to  the  occurrence 
of  albuminuria,  in  most  instances  daily  for  several  weeks.  He 
found  that  it  appeared  in  8 6 "6  per  cent,  of  his  typhoid  cases, 
and  in  88-8  per  cent,  of  the  typhus  ;  that  it  usually  proved 
temporary,  but  in  seven  cases  of  typhoid  and  eight  of  typhus 
persisted  as  long  as  the  patients  were  under  observation.  He 
found  that  the  albuminuria  tended  to  be  more  considerable  in 
typhus  than  in  typhoid,  and  that  in  both  it  was  more  severe 
than  in  scarlet.  It  was  usually  accompanied  by  tube  casts, 
and  other  tokens  of  distinct  organic  renal  lesion. 

If  we  could  obtain  with  regard  to  each  of  the  fevers 
similar  series  of  observations,  we  should  be  able  to  define  the 
relationships  of  the  individual  fevers  to  albuminuria  in  a  way 
that  we  cannot  at  present  accomplish.  My  object  in  seeking 
opportunity  for  examining  at  the  Fever  Hospital  was  simply 
to  get  a  general  idea  of  the  frequency  of  the  occurrence  of 
the  symptom  in  idiopathic  fevers,  and  of  course  the  subject 
naturally  emerged  in  analysing  the  other  groups  of  cases. 

An  interesting  relationship,  not  as  yet  by  any  means 
cleared  up,  exists  between  malarious  fever  and  chronic 
malarial  poisoning  on  the  one  hand,  and  albuminuria  on  the 
other.  I  have  no  means  of  knowing  in  what  proportion  of 
cases  of  malarious  fever  the  symptom  occurs,  but  certainly  it 
is  not  uncommon,  and  one  often  meets  with  cases  in  which 
albuminuria  has  developed  itself  in  those  who  have  suffered 
from  malarious  poisoning,  even  although  they  have  not  had 
ague.  It  appears  often  to  be  associated  with  a  degree  of 
inflammation  of  the  tubules,  and  to  be  attended  by  dropsy 


IN    FEVER.  127 

and  the  presence  of  a  few  tube  casts  ;  but  often  tube  casts 
are  difficult  to  find,  or  entirely  absent,  and  there  is  no  other 
token  of  renal  disease.  The  patients  often  improve  under 
treatment  with  quinine,  arsenic,  and  iron. 

It  has  long  been  known  that  albuminuria  occurs  in  the 
course  of  fever.  Among  the  first  to  draw  attention  to  the 
fact  was  Dr.  Warburton  Begbie.(86)  In  a  paper  on  "  Tem- 
porary Albuminuria,  more  particularly  as  occurring  in  the 
Course  of  certain  Febrile  and  other  Acute  Diseases,"  pub- 
lished in  1852,  he  pointed  out  the  frequency  of  its  occur- 
rence without  organic  renal  change.  He  met  with  it  in 
scarlet  fever,  in  typhus,  in  typhoid,  also  in  cholera,  and  in 
erysipelas,  pneumonia,  and  other  inflammations.  Since  that 
time  the  fact  has  been  universally  recognised  by  the  profes- 
sion as  a  matter  of  every  day  experience.  Idiopathic  fever 
in  all  its  forms,  septic  inflammations,  erysipelas,  diphtheria, 
inflammations  of  less  definitely  septic  character,  particularly 
pneumonia,  have  all  been  found  to  be  frequently  attended 
by  it. 

It  is  possible  that  relationships  may  be  discovered  between 
albuminuria  and  individual  local  inflammations.  This  possi- 
bility has  been  impressed  upon  me  by  the  interesting  and 
valuable  paper  published  a  few  years  ago  by  Dr.  Matthews 
Duncan, (87)  on  "Albuminuria  with  Parametritis."  He  showed 
that  of  16  uncomplicated  cases  of  that  disease,  6,  or 
3  7  J  per  cent.,  showed  albuminuria,  the  albumen  gradually 
disappearing  as  convalescence  from  the  parametritis  was 
established,  and  it  appeared  to  be  most  frequent  in  cases 
which  ultimately  went  on  to  suppuration.  Dr.  Matthews 
Duncan  was  satisfied  that  the  albuminuria  was  neither  due 
to  cystitis  nor  inflammation  of  the  kidneys,  for  no  excess  of 
mucus,  no  pus,  and  no  tube  casts  were  to  be  found.  In  a 
series  of  thirty-two  cases  of  perimetritis,  on  the  other  hand, 
he  found  that  albuminuria  did  not  occur. 


128  ALBUMINURIA. 

Drs.  Englisch (88)  and  Frank (89)  have  drawn  attention  to  the 
relationship  between  albuminuria  and  strangulated  hernia. 
The  latter  observer  found  in  3  9  cases  of  hernia  that  albumen 
was  present  in  24,  or  61  "5  per  cent.,  but  of  the  39,  12  were 
reduced  by  taxis,  and  in  them  only  one  showed  albuminuria, 
while  in  26  in  which  operation  was  required  22  showed  the 
symptom.  In  the  one  remaining  case  the  skin  was  already 
gangrenous,  and  albumen  was  present.  He  further  found 
that  the  more  severe  the  strangulation  the  more  constant 
was  the  albuminuria ;  the  patients  did  not  exhibit  the 
ordinary  signs  of  nephritis ;  neither  the  history,  the  micro- 
scopic examination  of  the  urine,  nor  the  progress  of  the  cases, 
corresponded  to  that  disease.  As  soon  as  strangulation  was 
relieved  albumen  disappeared  or  began  to  diminish,  and  it 
was  always  gone  by  the  end  of  three  days.  The  urine  was 
never  bloody,  but  blood- corpuscles  and  blood-casts  were 
sometimes  found  on  microscopic  examination.  Whether 
albuminuria  occurs  with  obstruction  of  the  bowel  from  other 
causes  I  am  not  prepared  to  say.  It  is  curious  to  notice 
that  Dr.  Matthews  Duncan  did  not  find  it  in  his  cases  of 
pelvic  peritonitis,  while  the  strangulation  is  evidently  an 
important  element  in  its  production  in  the  cases  of  hernia. 
It  was  very  natural  for  Dr.  Frank  to  suggest  as  an  explana- 
tion that  in  connection  with  the  obstruction  a  special  poison 
might  be  elaborated  and  absorbed  capable  of  producing  the 
renal  irritation,  but  it  is  difficult  to  frame  an  hypothesis 
which  might  serve  to  explain  Dr.  Matthews  Duncan's  facts. 

The  explanation  of  the  clinical  facts  has  been  the  subject 
of  much  speculation,  observation,  and  experiment.  To  begin 
with,  it  is  certain  that  in  a  large  proportion  of  these  febrile  and 
inflammatory  cases,  congestive  and  inflammatory  changes  in 
the  kidneys  exist,  the  changes  affecting  mainly  the  epithelial 
structures,  and  sometimes  the  stroma  of  the  organ.  On  post- 
mortem examination  of  the  fatal  cases  we  find  every  variety, 


ALBUMINUEIA    IN    FEVER.  129 

from  the  slightest  cloudy  swelling  to  the  most  pronounced 
alterations.  But  how  does  this  inflammation  arise  ?  Some 
have  supposed  that  it  is  caused  by  the  direct  action  of  fever 
germs  upon  the  renal  tissue.  Others  think  it  more  probable 
that  poisons  produced  by  these  germs,  either  from  themselves 
or  their  action  on  the  tissues,  are  the  actual  irritants.  Some 
experiments  seem  to  point  to  the  conclusion  that  the  renal 
change  may  be  induced  by  mere  elevation  of  temperature. 
Senator  found  that  albuminuria  was  always  produced  when 
the  bodily  temperature  was  raised  above  the  normal  by  from 
3*4  to  6 -7°  F.,  "  with  sufficient  rapidity,  or  the  heat  continued 
for  a  sufficient  length  of  time."  Blood  even  might  be  present 
if  a  very  high  temperature  were  rapidly  induced.  Even  when 
there  were  no  blood-corpuscles,  pale  hyaline  casts,  and  some- 
times finely  granular  ones,  were  found  in  the  urine.  He 
satisfied  himself  that  the  albuminuria  was  really  due  to  the 
high  temperature,  and  was  not  a  secondary  phenomenon 
manifested  while  the  temperature  was  falling.  The  kidneys 
were  hardened  by  boiling,  and  it  was  found  that  in  those 
least  affected  there  was  only  a  very  slight  deposit  of  albumen, 
not  visible  in  all  the  capsules  ;  whereas  in  the  more  violent 
cases  there  was  not  only  a  morbid  deposit  of  albumen,  but 
likewise  hsemorrhages  in  many  capsules  and  uriniferous 
tubules,  whilst  in  others  there  was  no  abnormality,  with  the 
exception  of  more  or  less  marked  hyperemia.  It  appears  to 
me  probable  that  it  may  arise  in  various  ways  :  sometimes, 
as  perhaps  in  diphtheria,  from  irritation  by  septic  organisms  ; 
sometimes  by  poisons  evolved  in  their  action  ;  and  sometimes 
by  the  influence  of  elevated  temperature ;  or  by  the  co-opera- 
tion of  more  than  one  of  these  influences. 

But  besides  these  cases  where  inflammation  of  the  kidney 
arises,  there  are  others  in  which  we  are  unable  to  demonstrate 
such  a  condition  ;  and  the  question  is,  How  is  the  albumin- 
uria in   these  cases  to  be  explained  ?     It  may  be   thought 

K 


130  ALBUMINURIA. 

that  it   is  really  a  result   of  slighter  degrees  of  irritation, 
and    so   it   no  doubt    is    in   many  cases ;    but,   apart  from 
this,   we    have    to    recognise    some    other    possible    causes. 
Experiment    has    shown    that    the    processes    of    transuda- 
tion through  membrane  become  quickened  when  tempera- 
ture is  raised.     If  you  take  a  membrane  and  set  a  saline  or 
albuminous  fluid  to  percolate  through  it,  you  will  find  that 
the  process  goes  on  much  more  quickly  when  the  temperature 
is  at  or  a  little  above  100°  Fahr.  than  it  does  at  the  normal 
temperature  of  the  air.     It  may  be  supposed,  then,  that  with 
the  rise  of  temperature  in  fever  the  renal  walls  become  more 
permeable  than  they  are  in  health.      But  the  rise  of  tempera- 
ture operates  in  another  way,  for  it  modifies  the  blood  pres- 
sure.    As  we  increase  the  heart's  action  the  arterial  tension 
rises,   and   such    increase  of  tension  may  in   some  measure 
favour  transudation  through  the  vascular  walls.      The  internal 
congestion  which  arises  when  the  temperature  is  raised  must 
have  its  influence  in  this  respect  also.     But  it  is  to  be  observed 
that  it  is  not  during  the  period  of  high  arterial  tension  in 
fever  that  albuminuria  is  most  apt  to  occur.      It  is  rather  at 
a  later  stage,  when  arterial  tension  has  become  lowered  either 
from  degenerative  changes  in  the  muscular  substance  of  the 
heart,  or  the  debilitating  influence  of  high  or  prolonged  fever, 
that  the  albuminuria  is  most  apt  to  occur,  and  then  the  con- 
gestion is  rather  in  the  venous  system,  and  it  must  be  due  to 
transudation  through  the  capillaries  surrounding  the  tubules, 
if  due  to  vascular  changes  at  all.     Lastly,  we  must  recognise 
as    another    possible    factor    in    the    production    of    febrile 
albuminuria  the  presence  of  albuminous  substances  in  the 
blood  different  from  normal  serum  albumen  and  globulin,  and 
perhaps  more  capable  of  transudation  through  vascular  walls. 
This,  which  is  at  present  purely  hypothetical,  may  one  day 
be  demonstrated  to  be  an  important  cause  of  this  albuminuria. 
It  is  important  to  inquire  what  degree  of  danger  attends  albu- 


FROM    DISEASE    OF    CIRCULATORY    SYSTEM. 


131 


minuria  in  fever.  It  seems  to  me  that  the  mere  presence  of  the 
substance  is  of  little  moment  so  long  as  it  is  merely  transient, 
and  does  not  lead  to  persistent  organic  change  in  the  kidney. 


Albuminuria  from  Disease  of  Circulatory  System. — In 
Table  XXII.  are  shown  the  results  of  our  observations  as  to 
the  incidence  of  albuminuria  from  these  causes  in  the 
different  groups  of  patients  examined. 


Table  XXII. — Showing  the  Incidence  of  Albuminuria 
from  Disease  of  the  Circulatory  System. 


No.  of 

Patients. 

With 
HN03. 

With 
Picric  Acid. 

Total. 

Per  cent. 

Private, 

Indoor  Infirmary,  . 
Outdoor  Infirmary, 
Royal  Hospital  for  Sick 
Children,    . 

150 
150 
100 

50 

1 

11 

4 

0 

1 
5 

1 

0 

2 

16 

5 

0 

This  table  shows  that  in  a  considerable  proportion  of  the 
cases  in  which  albuminuria  occurs  in  hospital  and  ordinary 
medical  practice,  the  condition  is  due  to  alterations  in  the 
circulatory  organs.  You  will  find,  when  you  watch  such 
cases  closely,  that  the  albuminuria  comes  and  goes  with  the 
disturbance  and  recovery  of  the  balance  of  circulation.  The 
greater  the  backward  pressure  in  the  systemic  veins,  the 
more  pronounced  is  the  albuminuria  ;  the  more  compensa- 
tion becomes  established,  the  less  is  the  symptom  apparent. 
Any  effort  tends  to  increase  the  amount  of  albumen  ;  rest  in 
bed  diminishes  it.  The  urine  presents  other  changes  worthy 
of  notice  :  it  is  apt  to  be  diminished  in  quantity,  of  high 
specific  gravity,  dark  in  colour,  depositing  urates,  but  con- 
taining a  good  amount  of  urea.  One  often  fails  to  find 
tube  casts  in  such  cases  after  the  most  careful  search,  but 
sometimes   hyaline    or  epithelial,    or    finely    granular  casts, 


132  ALBUMINUKIA. 

are  met  with  ;  but  wherever  epithelial  casts  are  distinct, 
we  have  a  token  that  a  measure  of  renal  inflammation  is 
present. 

When  we  ask  ourselves  how  this  variety  of  albuminuria 
is  to  be  explained,  increased  backward  pressure  is  at  once 
suggested  as  the  direct  cause.  In  all  the  cases  of  the  kind 
there  is  such  a  disturbance  of  the  balance  of  the  circulation  ; 
and  experiments  by  ligaturing  the  renal  veins  and  otherwise 
obstructing  the  circulation  have  shown  clearly  enough  that 
albuminuria  may  be  thereby  produced.  Ludwig  has  shown 
that  when  the  renal  vein  is  closed,  the  capillaries  round  the 
tubules  become  overfilled,  so  distended,  he  says,  as  sometimes 
to  close  the  urinary  tubules.  This  over-distension  gives  rise 
to  transudation  of  albumen,  and  that  not  occurring  in  the 
Malpighian  bodies  so  much  as  from  the  capillaries  surround- 
ing the  tubules.  The  experiments  of  Senator (20)  afford  con- 
clusive proof  as  to  the  seat  of  the  transudation.  He  ligatured 
the  renal  vein  for  a  few  minutes,  and  found  that  the  tubules 
contained  albumen,  while  the  glomeruli  remained  clear,  but 
that  if  he  allowed  the  obstruction  to  last  for  a  longer  time 
they  also  in  turn  became  the  seat  of  transudation.  Clinical 
observation  affords  a  beautiful  piece  of  evidence  that  the 
albumen  does  not  escape  from  the  glomeruli  in  patients 
suffering  from  cardiac  disease.  When  we  administer  digitalis 
to  such  a  patient  the  quantity  of  urine  rises,  and  the  albumen 
at  the  same  time  frequently  diminishes,  not  only  relatively, 
but  absolutely.  Now,  the  diuresis  is  explained  by  increase 
of  pressure  within  the  Malpighian  tufts.  This  increase  would 
necessarily  be  associated  with  increase  of  albumen  if  the 
capillary  loops  of  the  Malpighian  tufts  were  to  blame.  The 
evidence  seems  to  me  quite  sufficient  to  prove,  if  the  proof 
were  still  required,  that  increased  pressure  in  the  vessels 
surrounding  the  tubules  is  the  main  cause  of  this  form  of 
albuminuria.      It  is  true  that  changes  not  unfrequently  occur 


WITH    DISEASES    OF    ALIMENTAKY    SYSTEM. 


133 


in  the  epithelium  and  the  interstitial  tissue,  but  many  cases 
exhibit  no  such  alteration  ;  and  when  they  do  exist,  they  are 
to  be  regarded  as  further  additions  to  the  morbid  process. 
I  know  of  no  evidence  pointing  to  alterations  of  the  vessel 
walls  or  altered  conditions  of  blood  as  favouring  the  produc- 
tion of  the  symptom  in  cardiac  cases. 


Albuminuria  associated  with  diseases  of  the  alimentary 
system  is  much  less  common  than  the  groups  of  which 
I  have  hitherto  spoken.  In  Table  XXIII.  its  incidence 
is  shown  in  my  different  series  of  cases. 

Table  XXIII. — Showing  the  Incidence  op  Albuminuria  prom 
Disease  op  the  Alimentary  System. 


No.  of 
Patients. 

With 
HN03 

With 
Picric  Acid. 

Total. 

Private,           .         . 
Indoor  Infirmary,  . 
Outdoor  Infirmary, 
Royal  Hospital  for  Sick 
Children,     . 

150 
150 
100 

50 

1 
1 

0 

0 

2 

5 
1 

0 

3 
6 

1 

0 

Alimentary  derangements  which  are  thus  shown  to 
associate  themselves  with  albuminuria  are  very  various. 
Functional  and  catarrhal  gastric  affections,  organic  disease, 
such  as  cancer  of  stomach,  intestinal  disease  with  diarrhoea, 
strangulated  hernia,  and  perhaps  other  causes  of  obstruction, 
and  various  functional  and  organic  alterations  of  the  liver, 
are  known  to  stand  in  relation  to  it. 

One  is  necessarily  reminded  in  considering  this  group 
of  the  fact  that  the  ingestion  of  food  in  many  healthy  people 
is  followed  by  slight  transient  albuminuria.  It  is  natural 
that  in  conditions  where  the  digestive  process  is  interfered 
with  this  should  be  still  more  frequent.  We  have  some 
reason  to  think  that  the  albuminuria  in  these  cases  may  be 


134  ALBUMINURIA. 

referred  to  altered  blood  pressure,  or  to  altered  chemical 
composition  of  the  blood  serum,  or  to  both.  But,  in  some 
cases,  it  would  appear  that  ulcerated  surfaces  may  permit  of 
the  absorption  of  albuminous  materials,  which  come  to  be 
discharged  by  the  kidneys  unchanged.  The  observations 
in  regard  to  the  relationship  of  ulcerating  carcinoma  of 
the  stomach  and  peptonuria  are  in  this  respect  specially 
worthy  of  attention. 

The  albuminuria  attending  upon  diarrhoea,  as  well  as  that 
so  often  observed  in  cases  of  cholera,  might  perhaps  be 
referred  in  part  to  the  diminished  amount  of  water  in  the 
blood ;  but,  as  I  have  shown,  it  is  much  more  likely  that  it 
results  from  changes  in  the  state  of  the  filtering  apparatus. 

The  variety  met  with  in  association  with  hepatic  derange- 
ments may,  I  think,  be  ascribed  partly  to  morbid  materials 
introduced  into  the  blood  in  consequence  of  these  derange- 
ments, partly  to  irritation  of  the  kidneys  by  such  morbid 
products,  and  partly  to  coincident  alterations  of  the  cir- 
culation in  the  kidney  corresponding  with  those  existing 
in  the  liver. 

The  late  Dr.  Murchison (90)  and  Dr.  George  Harley(91)  have 
both  pointed  out  very  distinctly  the  tendency  to  albuminuria 
in  diseases  of  the  liver.  Murchison  refers  to  this  tendency  in 
many  diseases  affecting  that  organ.  In  some,  as  in  cirrhosis, 
the  kidneys  are  liable  to  be  affected  similarly  to  the  liver. 
In  others,  he  points  out  that  renal  degeneration  may  be 
induced  by  the  continued  elimination  of  products  of  faulty 
digestion  through  the  kidneys.  In  others  albuminuria  may 
result  from  a  mechanical  effect  on  the  kidneys,  as  when  the 
venous  outflow  from  them  is  obstructed  by  the  pressure 
produced  by  ascites.  There  is  also,  he  says,  reason  to 
believe  that  albuminuria  may  be  induced  by  hepatic  derange- 
ment independently  of  structural  disease  of  the  kidneys,  the 
symptom  being  very  often  intermittent  or  remittent.     The 


WITH    DISEASES    OF    THE    NERVOUS    SYSTEM. 


135 


albumen  in  this  condition,  lie  finds,  has  certain  peculiarities, 
the  addition  of  a  little  acid  very  readily  preventing  coagula- 
tion by  heat.  The  urine  is  of  normal  quantity,  of  high  specific 
gravity,  habitually  loaded  with  lithates,  lithic  acid,  oxalates, 
and  pigments.  The  albuminuria  may  be  explained  either  by 
the  liver  having  too  much  proteid  to  transform,  or  by 
deficiency  of  the  chemical  activity  of  the  liver — in  either 
case  albumen  being  discharged  unchanged.  You  will 
remember  what  I  have  elsewhere  said  as  to  the  liberation 
of  albumen  from  the  red  blood-corpuscles  destroyed  during 
their  passage  through  the  liver.  I  have  only  to  mention 
this  here  to  bring  to  your  mind  its  bearing  in  relation 
to  the  production  of  albuminuria  from  hepatic  derangement. 
Dr.  George  Harley  expresses  views  very  similar  to  those 
of  Murchison.  He  describes  a  condition  which  he  designates 
"  hepatic "  albuminuria,  dependent  on  disease  of  the  liver, 
and  characterised  by  the  discharge  of  a  normal  amount  of 
urine  of  good  or  even  high  specific  gravity,  containing  casts 
of  the  renal  tubules.  He  emphasises  the  value  of  treatment 
of  the  liver  in  such  cases. 


Albuminuria  associated  with  diseases  of  the  nervous 
system  is  not  of  very  frequent  occurrence.  In  Table  XXIV. 
I  have  shown  its  incidence  in  my  different  groups  of 
cases. 


Table  XXIV. — Showing  the  Incidence  of  Albuminuria 

ASSOCIATED    WITH    DISEASES    OF    THE    NERVOUS    SYSTEM. 


No.  of 
Cases. 

With 
HN03. 

With 
Picric  Acid. 

Total. 

Private, 

Indoor  Infirmary,  . 
Outdoor  Infirmary, 
Royal  Hospital  for  Sick 
Children,     . 

150 
150 
100 

50 

0 
1 
0 

0 

0 
4 
0 

1 

0 
5 
0 

1 

136  ALBUMINURIA. 

Among  these  there  were  two  cases  of  epilepsy,  one  showing 
with  nitric,  the  other  only  with  picric  acid  ;  there  were  two 
of  exophthalmic  goitre,  one  of  infantile  paralysis,  and  one  of 
multiple  sclerosis,  all  showing  only  with  picric  acid.  We  did 
not  happen  to  have  cases  of  hemorrhagic  apoplexy  or  other 
nervous  disease  exhibiting  the  symptom  during  the  time  that 
the  observations  were  made.  In  my  cases  of  exophthalmic 
goitre  the  albuminuria  did  not  present  the  peculiar  features 
which  occurred  in  the  case  which  led  to  the  discovery  of  this 
relationship  by  Dr.  Warburton  Begbie.(92)  For  in  his  case  the 
albumen  was  very  copious,  and  occurred  mostly  after  break- 
fast ;  in  ours  it  was  scanty.  It  may  be  interesting  to  those 
familiar  with  the  admirable  paper  of  Dr.  Warburton  Begbie 
to  know  that  his  patient  has  now  for  years  been  quite 
well,  the  goitre  and  the  albuminuria  having  both  entirely 
disappeared. 

With  regard  to  the  question  of  the  relationship  of  albu- 
minuria to  nervous  disease,  there  has,  in  my  opinion,  been 
a  good  deal  of  inaccurate  observation  and  rash  assertion,  and 
I  believe  that  a  thorough  clinical  investigation  of  the 
relationship,  extended  over  a  long  series  of  cases,  is  much 
wanted.  How  often  does  it  occur  in  cases  of  concussion  of 
brain  or  cord  ?  How  often  is  it  met  with  in  haemorrhage  or 
other  central  lesions,  and  what  are  the  special  seats  of  lesion 
with  which  it  is  most  apt  to  be  associated  ?  Is  it  really  as 
common  an  after-symptom  of  epilepsy  as  some  have  sup- 
posed ?  Such  questions  I  should  like  to  see  answered. 
I  have  not  myself  been  able  to  collect  a  sufficient  number  of 
facts,  but  as  we  have  seen,  the  proportion  among  the  usually 
alcoholic  inmates  of  the  delirium  tremens  wards  of  the  Royal 
Infirmary  has  not  been  so  great  as  might  have  been  antici- 
pated among  the  forty  cases  that  I  examined. 

In  regard  to  the  explanation  of  the  symptom  in  the 
cases  in  which  it  does  occur  we  cannot  speak  very  positively, 


WITH    GLYCOSURIA. 


137 


as  I  have  already  shown.  Its  occurrence  in  diseases  of  the 
cord  is  usually  at  least  a  result  of  catarrh  of  bladder,  and 
therefore  such  cases  are  referable  to  the  accidental  group. 
With  regard  to  prognosis  it  does  not  seem  to  afford  any 
indication. 


The  association  of  albuminuria  ivith  glycosuria  is  one 
which  we  sometimes  meet  with,  and  in  Table  XXV.  I  give 
the  statistics  as  to  its  occurrence  in  the  different  series  of 
cases  examined. 


Table  XXV. — Showing  the  Incidence  of  Albuminuria 

ASSOCIATED   WITH    GLYCOSURIA. 


No.  of 

Cases. 

With 
HN03. 

With 
Picric  Acid. 

Total. 

Private, 

Indoor  Infirmary,  . 
Outdoor  Infirmary, 
Royal  Hospital  for  Sick 
Children,    . 

150 
150 
100 

50 

2 
2 
0 

0 

0 
1 
1 

0 

2 
3 
1 

0 

Dr.  Arnold  Pollatschek,  of  Carlsbad,(93)  has  recently  pub- 
lished a  paper  showing  that  during  two  successive  years  about 
37  per  cent,  of  the  urines  which  he  found  to  contain  sugar 
also  contained  albumen.  The  frequency  of  the  association 
would  thus  appear  to  be  much  greater  than  has  been 
generally  supposed. 

The  explanation  of  the  symptom  is  doubtless  different 
in  different  cases.  In  some  it  is  due  to  acute  inflammation 
of  the  kidney  ;  in  others,  probably  to  nervous  influence, 
possibly  sometimes  to  changes  in  the  blood.  But  the  occur- 
rence of  albuminuria  in  cases  of  diabetes  is  always  of  very 
serious  omen. 


LECTURE    XL 

ALBUMINURIA— PAROXYSMAL— DIETETIC— FROM 
EXERCISE— SIMPLE  PERSISTENT. 

Four  Categories. — Sketch  of  Progress  of  Knowledge  on  this  Subject. 
— Christison.  —  Jaccoud.  —  Moxon. — Gull. — Morley  Rooke.  — 
Burney  Yeo.  —  Clement  Dukes.  —  Mahomed.  —  Fiirbringer.  — 
Runeberg.  —  Saundby.  — Leube.  —  George  Johnson.  —  Quain. — 
Stanley  Rendall.  — Pavy.  — Maguire. 

Paroxysmal  Albuminuria. — Illustrative  Case. — Relation  to  Paroxy- 
smal Hemoglobinuria.  — Explanation. — Treatment. 

Dietetic  Albuminuria. — Illustrative  Cases. — Positive  and  Negative. — 
Theoretical  Explanations. — Treatment. 

A  Ibuminuriafrom  Muscular  Exertion. — Illustrative  Cases. — Summing 
up  of  Features. — Theoretical  Explanation. — Treatment. 

Simple  Persistent  Albuminuria. — Illustrative  Cases. — Summing  up  of 
the  Features. — Theoretical  Explanation. — Treatment. 

Prognosis  in  the  Four  Varieties. 

pENTLEMEN,  —  In  this  lecture  I  shall  discuss  some 
varieties  of  albuminuria  not  dangerous  to  life  of  which 
few  examples  occurred  in  the  series  of  cases  which  I  selected 
as  the  basis  for  this  discussion,  but  which  have  attracted  a 
considerable  amount  of  attention  in  recent  years.  They 
have  been  variously  designated  functional,  intermittent, 
dietetic,  cyclical  albuminuria,  also  the  albuminuria  of  adoles- 
cence. They  may  be  variously  grouped,  but  it  seems  clear 
that  at  present  four  categories  at  least  may  be  defined,  which, 
although  they  run  into  one  another  and  mutually  overlap, 

perhaps  varying  in  the  same  individual  from  time  to  time, 
138 


FUNCTIONAL    ALBUMINURIA.  139 

may  yet  with  advantage  be  distinguished.  These  are,  1st, 
paroxysmal  albuminuria ;  2nd,  dietetic  albuminuria ;  3rd, 
albuminuria  from  muscular  exertion  ;  and  4th,  simple  per- 
sistent albuminuria.  I  do  not  know  whether  this  classifica- 
tion will  ultimately  turn  out  the  most  satisfactory,  but  I  can 
illustrate  each  of  the  varieties  with  cases  markedly  charac- 
teristic. 

In  a  few  words  I  may  explain  the  substance  of  what  I  deem 
the  most  important  contributions  to  the  subject  in  recent 
literature.  Many  years  ago  Sir  Kobert  Christison (94)  pointed 
out  that  the  use  of  certain  articles  of  diet  and  luxury  some- 
times induces  temporary  albuminuria.  Jaccoud (95)  formulated 
the  statement  that  there  are  cases  of  persistent  albuminuria 
in  which  the  patient  is  substantially  in  good  health,  and  in 
which  there  is  no  kidney  disease.  He  therefore  distinguished 
between  persistent  albuminuria  and  albuminuria  from  Bright's 
disease.  Dr.  Moxon(96)  gave  definiteness  to  our  ideas  by  his 
paper,  published  in  1878,  on  chronic  intermittent  albuminuria. 
He  divided  cases  of  this  kind  into  two  classes  :  1st,  the  albu- 
minuria of  adolescence,  in  which  the  symptom  continues  during 
a  long  period  in  a  desultory  and  irregular  way,  so  that  in 
some  it  is  rather  occasional  than  intermittent ;  2nd,  remittent 
albuminuria,  in  which  the  albuminuria  is  in  greater  quantity 
and  occurs  more  constantly  from  day  to  day,  especially  in 
the  urine  passed  after  breakfast,  but  is  usually  wanting  in 
that  passed  in  the  early  morning.  He  further  divided  these 
remittent  cases  into  two  groups,  in  one  of  which  there  is 
renal  disease,  in  the  other  none.  With  regard  to  the 
albuminuria  of  adolescence,  Dr.  Moxon  pointed  out  that  it  is 
a  state  of  health  to  which  young  men  are  subject,  which  from 
its  frequency  deserves  a  special  name.  The  patient  is  out  of 
condition,  listless,  and  languid,  sleeps  too  much,  and  yet 
rises  unrefreshed,  is  ansemic,  and  grey  and  sunken  about  the 
eyes.      It  is  simply  a  state  of  debility  without  any  organic 


140  ALBUMINUKIA. 

disease.  The  urine  is  found  to  be  at  times  albuminous — 
most  often  after  breakfast — while  at  other  times  it  is  quite 
free  from  albumen.  He  had  met  with  nineteen  cases  of  it, 
and  of  the  seven  cases  which  he  records,  two  pairs  were 
brothers,  while  another  brother  in  one  of  the  families  affected 
was  under  his  care  with  a  different  urinary  abnormality — 
the  persistent  presence  of  a  large  excess  of  urea.  This  paper, 
as  I  have  said,  defined  our  knowledge,  but  that  the  existence 
of  non-dangerous  albuminuria  was  an  idea  familiar  to  acute 
physicians  may  be  shown  by  the  fact  that  Sir  William  Gull 
had  told  Dr.  Moxon  that  in  his  experience  albuminuria  is 
almost  as  common  in  young  and  growing  men  and  boys  as 
spermatorrhoea.  Dr.  T.  Morley  Eooke (97)  drew  attention  to  the 
remarkable  effect  of  rest  in  the  recumbent  posture  in  remov- 
ing or  keeping  in  abeyance  the  albuminuria  of  adolescence  ; 
and  Dr.  Burney  Yeo(98)  dwelt  upon  the  importance  of 
muscular  exercise  as  a  cause,  and  of  rest  in  bed  and 
the  effect  of  food  and  wine  as  means  of  lessening  the 
albuminuria. 

Dr.  Clement  Dukes,(99)  discussing  the  albuminuria  of  adol- 
escence on  the  basis  of  his  experience  as  Physician  to  Eugby, 
pointed  out  that  it  is  extremely  common  and  presents  a  great 
variety  of  features,  both  in  its  causation  and  special  char- 
acters. Sometimes  a  sudden  change  in  temperature,  some- 
times an  error  in  diet,  sometimes  excessive  exertion,  sometimes 
mental  emotion  induces  it.  He  showed  that  sometimes  the 
diet  has  no  effect,  at  others  the  most  marked,  so  that  a 
patient  who  has  no  albuminuria  when  taking  milk,  may  get 
it  when  he  adds  a  little  bread  to  his  diet,  and  one  who,  going 
about,  requires  to  limit  his  food  in  the  strictest  way,  can  eat 
and  drink  freely  if  he  remains  in  bed.  It  may  be  persistent 
for  a  very  long  time,  or  it  may  disappear  and  reappear  ;  it 
it  may  be  absent  at  one  time  of  the  day  and  present  at 
another. 


CYCLIC    ALBUMINURIA.  141 

I  shall  not  detail  anything  of  the  important  contributions 
of  Mahomed,(100)  Furbringer,(30)  Runeberg,(101)  Saundby,(102) 
Leube,(103)GeorgeJohnson/29)Quain,<lw)Capitan,(23)Semmola;<105) 
Von  Noorden,(106)  Keene  of  Philadelphia,(107)  and  Stanley 
Rendall,(10S)  but  pass  at  once  to  a  communication  by  Dr. 
Pavy,(109)  made  at  the  British  Medical  Association  meeting 
in  1885,  in  which  he  suggests  the  name  cyclic  albuminuria, 
and  gives  interesting  details  of  a  number  of  cases.  He 
describes  the  diurnal  appearance  and  disappearance  of 
the  albumen  very  much  as  Dr.  Moxon  did.  There 
may,  he  says,  be  considerable  variation  in  the  amount 
of  albumen  on  different  days.  It  may  go  on  for  weeks, 
months,  or  years,  without  impairment  of  health.  There  may 
be  sharp,  unduly  forcible  cardiac  impulse,  but  the  pulse  is 
soft,  not  hard  and  sustained.  There  is  nothing,  he  says,  to 
show  that  it  is  an  early  stage  of  Bright's  disease,  or  that  it 
leads  to  any  serious  disorder.  The  urine  is  otherwise  normal 
as  a  rule,  with  no  casts,  but  occasionally  sugar  has  been 
detected,  while  oxalate  of  lime  crystals  are  frequently 
present.  The  age  of  patients  observed  varied  from  nine  to 
forty-nine.  Three  cases  were  in  children  aged  nine,  eleven, 
and  thirteen  respectively,  two  boys  and  one  girl.  Dr.  Pavy 
offers  no  theory,  but  compares  the  condition  with  some 
analogous  phenomena  of  a  diurnal  character.  Thus,  in  the 
phosphatic  diathesis  the  urine  may  be  normal  in  the  early 
morning,  whilst  for  a  few  hours  after  breakfast  it  is  turbid 
from  the  presence  of  phosphates,  becoming  clear  again  in  the 
afternoon  and  remaining  so  till  after  breakfast  next  day. 
There  is  also  a  diurnal  variation  in  the  temperature  of  the 
body.  Thus  a  physiological  cyclic  change  exists  of  which 
other  illustrations  could  be  adduced.  This  paper  has  given 
fresh  impetus  to  the  study  of  these  cases, 

Dr.  Maguire,(110)  in  an  able  and  interesting  communication, 
has    suggested    that    we    may    recognise     three     classes    of 


142  ALBUMINURIA. 

functional  or  cyclic  albuminuria  :  1st,  those  accompanied  by 
general  languor,  low  tension  pulse,  and  no  deposit  of  uric 
acid  in  the  urine  ;  2nd,  those  with  robust  health,  pulse  of 
high  tension,  frequently  some  dyspepsia,  and  a  copious 
deposit  of  uric  acid ;  3rd,  rare  cases  in  which  some  abnormal 
albumen  is  present  in  the  urine. 

Having  thus  given  an  idea  of  some  of  the  chief  recent 
observations  on  this  subject,  I  proceed  to  describe  and  illus- 
trate our  four  varieties. 

I.  Paroxysmal  Albuminuria.  I  shall  perhaps  best  convey 
an  idea  of  the  features  of  this  form  of  albuminuria  if 
I  describe  a  typical  case  which  I  studied  in  the  wards  of  the 
Old  Infirmary.  A  young  woman  was  admitted  on  account 
of  acute  illness.  She  had  general  malaise,  some  degree  of 
fever,  and  gastric  catarrh,  but,  on  examination,  nothing 
further  could  be  discovered  amiss,  excepting  that  the  urine 
was  rather  scanty,  dark  in  colour,  and  was  loaded  with 
albumen.  The  microscope  showed  tube  casts  in  great 
number  and  of  several  varieties — epithelial,  granular,  and 
hyaline.  There  were  also  some  crystals  of  oxalate  of  lime. 
There  was  a  degree  of  puffiness  of  the  face,  but  no  dropsy, 
and,  notwithstanding  the  urgency  of  the  renal  symptoms, 
I  ventured  to  express  the  opinion  that  the  illness  would 
prove  transient  and  unimportant.  My  reasons  for  so  doing 
were  the  suddenness  of  development  of  the  renal  symptoms, 
and  the  discrepancy  between  them  and  the  general  condition 
of  the  patient  ;  and  the  opinion  was  further  confirmed  when 
it  transpired  that  similar  attacks  had  previously  occurred  and 
had  speedily  passed  off.  The  next  day  the  patient  was  much 
better  ;  the  albumen  was  disappearing,  the  tube  casts  were 
no  longer  so  numerous,  and  before  many  hours  had  elapsed 
she  was  quite  well. 

This  form  of  albuminuria  stands  in  very  interesting  rela- 
tionship to  what  is  called  paroxysmal  hsematinuria  or  hsemo- 


PAROXYSMAL    ALBUMINURIA.  143 

globinuria,  a  disease  which  is  ascribed  by  many  to  a  morbid 
action  of  the  liver.  The  patient  in  the  intervals  between  the 
paroxysms  may  appear  to  be  in  good  health.  The  attack 
begins  with  a  slight  feeling  of  chilliness,  or  a  rigor  attended 
by  some  uneasiness  in  the  region  of  the  liver  and  in  the  small 
of  the  back.  The  urine  is  of  a  dark  colour,  due  to  the  pre- 
sence of  blood  pigment.  As  a  rule,  the  colour  is  due  simply 
to  haemoglobin,  but  sometimes  blood  corpuscles  may  be 
detected  when  the  fluid  is  freshly  passed.  They,  however, 
even  when  present,  tend  to  break  down,  and  the  blood  pigment 
is  liberated.  There  is,  therefore,  in  this  disease  a  hsemolytic 
process,  a  destruction  of  red  blood-corpuscles  probably  due  to 
some  temporary  derangement  of  the  liver,  and  the  liberated 
pigment  is  discharged  by  the  kidneys.  A  single  micturition 
may  discharge  all  the  haemoglobin  which  has  been  set  free, 
or  it  may  appear  during  two  or  three  micturitions.  Now  I 
think  I  may  more  clearly  bring  out  the  close  relationship 
which  exists  between  this  disease  and  that  which  I  have 
called  paroxysmal  albuminuria,  by  relating  a  case  described 
by  Eosenbach.(111) 

A  little  boy,  seven  years  old,  after  a  severe  fall  from  a 
waggon,  became  subject  to  attacks  of  periodical  haemoglobin- 
uria.  The  attacks  occurred  pretty  frequently,  and  exhibited 
the  features  common  in  the  disease.  The  most  interesting 
point  for  our  present  purpose  is  that  at  the  beginning  of  each 
attack,  before  the  haemoglobin  appeared,  the  urine  became 
albuminous.  This  is  by  no  means  an  exceptional  circum- 
stance ;  indeed,  it  will  be  found  in  many  cases  of  hsemo- 
globinuria.  It  is  probable  that  the  process  originates  either 
in  the  nervous  system,  inducing  a  morbid  action  of  the  liver, 
or  in  a  primary  affection  of  that  gland  ;  and  that  it  causes 
blood  changes  which  irritate  the  kidneys,  giving  rise  to  a 
transient  inflammatory  action  during  the  process  of  elimina- 
tion of  the  waste  products.      Whether  this  view  of  the  patho- 


144  ALBUMINURIA. 

genesis  of  the  process  be  correct  or  not,  the  clinical  relation- 
ship of  hemoglobinuria  to  the  form  of  albuminuria  we  are 
now  discussing  is  unmistakable.  The  relationship  is 
rendered  the  more  distinct  by  their  etiology,  for,  like  those 
of  paroxysmal  hemoglobinuria,  the  attacks  of  paroxysmal 
albuminuria  are  apt  to  be  brought  on  by  cold  and  wet,  some- 
times by  errors  of  diet  and  alcoholic  intoxication. 

The  characteristic  features  of  this  group  of  cases  are  easily 
recognised.  The  sudden  and  copious  occurrence  of  albumen 
in  the  urine  with  numerous  casts,  the  process  lasting  only  a 
short  time  and  recurring  at  intervals  with  or  without  a  per- 
ceptible exciting  cause,  will  justify  you  in  diagnosing  the 
condition. 

What  view  are  we  to  take  as  to  the  explanation  of  the 
process  ?  Is  it  to  be  referred  to  changes  in  the  secreting 
structures,  in  the  blood-vessels,  or  in  the  blood  itself  ?  Con- 
sidering that  we  have  so  marked  a  discharge  of  casts  and 
epithelial  cells,  it  is  obvious  that  we  must  admit  changes  in 
the  secreting  structures.  Alterations  in  the  blood  pressure 
may  exist,  but  only  as  a  secondary  element.  Changes  in  the 
blood  itself,  although  not  demonstrated,  are,  in  my  opinion, 
extremely  probable,  and  they  most  likely  induce  the  altera- 
tion in  the  kidneys.  Irritation  of  the  kidneys  from  blood 
changes  is  a  very  common  phenomenon.  You  must  fre- 
quently have  noticed  how,  in  cases  of  many  varieties  of  jaun- 
dice, albumen  and  tube  casts  appear  in  the  urine,  and  this 
evidently  as  a  result  of  irritation  of  the  kidney  by  the  products 
of  the  hepatic  disorder.  In  cases  of  oxaluria  a  similar  change, 
probably  depending  upon  a  corresponding  cause,  is  often 
seen.  The  analogy  with  the  hemoglobinuria  process  supplies 
another  consideration  in  favour  of  the  view.  Such  is  the 
hypothetical  explanation  which  at  present  commends  itself 
to  my  judgment. 

II.   Dietetic  Albuminuria  is  a  variety  which  has  long  been 


DIETETIC    ALBUMINURIA CASES.  145 

more  or  less  distinctly  recognised.  Some  people  suffer  from 
it  whenever  they  indulge  in  certain  articles  of  diet.  In  some 
cases  one  kind  of  food,  in  others  many  require  to  be  pro- 
scribed ;  cheese,  pastry,  and  eggs  are  among  the  more  common 
offenders.  My  first  experience  of  such  cases  was  obtained 
when  I  held  the  office  of  resident  physician  in  the  clinical 
wards  of  the  Infirmary.  A  member  of  the  staff  used  some- 
times to  make  his  appearance  with  a  pasty,  puffy  condition 
of  eyelids,  and  he  found  that  this  was  associated  with  albu- 
minuria. His  albuminuria  proved  to  be  dietetic.  If  he 
indulged  in  even  a  moderate  amount  of  cheese  or  of  pastry 
the  symptom  was  pretty  sure  to  arise.  Such  a  passing  and 
temporary  albuminuria  always  and  exclusively  following  upon 
error  of  diet  is  easily  made  out  and  avoided.  On  the  other 
hand,  there  are  some  cases  in  which  the  albuminuria  is  little, 
if  at  all,  determined  by  the  kind  of  food,  but  the  entrance  of 
food  of  any  sort  into  the  stomach  suffices  to  induce  the 
symptom  ;  and  there  are  many  in  which  the  food  determines 
the  occurrence  of  albumen,  and  in  which,  nevertheless,  some 
other  factor  also  plays  an  important  part  in  its  production. 
In  dietetic  albuminuria  we  must,  therefore,  recognise  at  least 
these  three  factors  as  possible  exciting  causes  :  first,  the  use 
of  certain  kinds  of  food ;  second,  the  entrance  of  food  (of  any 
kind)  into  the  stomach  ;  and,  third,  one  or  both  of  these,  in 
association  with  other  influences,  such  as  exercise  or  time  of 
day.  It  will  be  readily  gathered  from  the  examples  to  be 
described,  that  each  of  these  factors  has  a  very  different 
amount  of  influence  in  different  cases,  the  symptom  being 
chiefly  due  to  one  in  some  cases,  to  another  in  others. 

I  shall  illustrate  this  variety  by  a  negative  and  a  positive 
instance.  A  gentleman  consulted  me  some  years  ago  on 
account  of  albuminuria,  and  when  I  was  searching  for  the 
cause  it  transpired  that  his  dietetic  habits  were  such  as  might 
well  have  accounted  for  the  symptom.      He  was  accustomed 


146  ALBUMINURIA. 

to  a  luxurious  table,  and  acknowledged  a  special  partiality 
for  cheese.  I  asked  him  which  were  his  favourites.  He 
named  Stilton,  Rochefort,  and  Gorgonzola.  I  inquired  as  to 
the  quantity,  and  he  indicated  that  a  piece  three  inches  long, 
an  inch  and  a  quarter  broad,  by  at  least  an  inch  thick,  was 
his  usual  allowance.  I  expected  that  this  would  prove  to 
be  an  important  causal  element  in  his  case,  and  after  various 
other  experiments  I  directed  him  to  take  a  good  piece  of  one 
of  his  favourite  cheeses,  but  found  that  no  albuminuria  fol- 
lowed. Indeed,  I  found  that  diet  had  little  or  no  effect  upon 
his  urine.  On  testing  it  after  dinner  on  one  occasion  I  found 
that,  although  the  meal  had  included  a  good  allowance  of 
pate  de  foie  gras,  chicken  croquets,  roast  pigeon  with  spinach, 
gooseberry  tart,  and  a  pint  of  Marcobrunner,  the  urine  was 
normal.  On  another  occasion,  when  a  Welsh  rarebit  con- 
stituted part  of  the  meal,  a  like  result  appeared.  I  found 
also  that  a  breakfast  of  fried  sole,  a  cup  of  coffee  with  milk, 
and  a  pint  of  milk  with  bread  did  not  produce  albuminuria, 
and  a  sumptuous  luncheon  was  alike  inoperative.  The  only 
food  which  seemed  to  induce  the  albuminuria  was  newly 
baked  hot  bread.  Thus,  it  was  clear  that  my  first  impression 
was  wrong,  and  that  the  albuminuria  in  this  case  was  not  of 
dietetic  origin.  I  shall  show  further  on  what  its  cause  really  was. 
I  shall  now  refer  to  a  case  in  which  a  positive  effect  was 
apparent.  The  patient,  then  a  medical  student,  called  upon 
me  first  in  the  autumn  of  1881,  complaining  of  headache 
and  dyspepsia.  The  heart's  action  was  not  satisfactory,  but 
gave  no  indications  of  structural  change  either  in  the  organ 
itself  or  in  the  kidneys.  There  was  distinct,  although  not 
copious,  albuminuria,  unattended  by  tube  casts  or  other 
token  of  organic  renal  disease.  I  ordered  him  a  mixture 
containing  chloride  of  ammonium  and  tincture  of  perchloride 
of  iron.  In  the  course  of  a  week  the  albumen  had  diminished 
to  a  faint  trace,  and  by  the  end  of  a  fortnight  it  had  dis- 


DIETETIC    ALBUMINURIA CASES.  147 

appeared  entirely.  It  did  not  recur  until  the  following 
summer,  when  his  vigour  was  reduced,  owing  to  the  work  for 
the  final  examination  and  to  anxiety  in  connection  with  the 
death  of  his  father.  It  was  then  observed  that,  although 
not  present  in  the  morning  urine,  there  was  a  distinct  trace 
immediately  after  food  entered  the  stomach.  The  rapidity  of 
its  onset  was  very  remarkable.  As  soon  as  food  of  any  sort 
was  taken  albumen  began  to  be  discharged  by  the  kidneys. 
Being  by  this  time  a  well-educated  medical  man,  he  was 
much  interested  in  this  circumstance,  and  found  by  experi- 
ment that  if  after  commencing  a  meal  he  passed  a  little  water, 
it  was  sure  to  be  albuminous,  although  that  passed  a  few 
minutes  before  was  not.  But  the  symptom  was  influenced 
also  by  the  season  of  the  year  and  the  time  of  the  day. 
It  occurred  only  in  summer  and,  while  easily  induced  in  the 
morning  or  at  midday,  it  never  appeared  during  the  evening 
or  at  night.  It  had  its  special  periods,  but  even  during 
them  the  ingestion  of  food  was  the  determining  element. 
The  breakfast  and  the  midday  meal  always  produced  it,  but 
never  was  a  trace  discoverable  in  the  evening,  whatever  food 
was  taken.  The  nature  of  the  diet  had  at  all  times  very 
little  effect.  If  he  lived  upon  rich  food  the  albuminuria 
became  no  worse.  If  he  made  Kevalenta  Arabica  and  such 
like  substances  his  diet,  it  appeared  all  the  same.  Even  a 
milk  diet  seemed  to  produce  no  favourable  effect,  but  he 
could  not  persevere  in  its  use,  as  it  did  not  suit  him. 

The  results  of  exercise  were  carefully  tested.  They  were 
found  distinct,  but  much  less  marked  than  those  of  food. 
If  he  fasted  of  a  morning,  no  amount  of  exertion  induced  the 
albuminuria.  But  if,  when  the  albuminuria  had  been  induced 
by  eating,  he  took  exercise,  the  quantity  of  albumen  at  once 
greatly  increased.  On  the  other  hand,  as  with  food,  exertion 
failed  to  produce  it  during  what  I  may  call  the  non- 
albuminuric  portion  of  the  twenty-four  hours. 


148  ALBUMINURIA. 

There  never  were  any  tube  casts,  but  oxalates  were 
frequently  present.  The  urine  was  occasionally  high  coloured, 
never  bloody,  sometimes  deposited  urates  but  never  uric  acid. 
He  never  had  pain  in  the  back  or  other  local  symptoms  to 
draw  his  attention  to  the  renal  functions.  The  albuminuria 
thus  recurred  each  summer  till  1885,  when  it  was  very  slight, 
and  in  1886  it  did  not  make  its  appearance.  The  last  speci- 
men of  urine  examined  was  natural  in  colour,  specific  gravity 
while  warm,  1'020,  distinctly  acid,  and  contained  no  albumen 
or  sugar.  The  condition  of  the  heart  is  the  same  as  it  was 
in  1881.  The  state  of  the  vessels  is  also  the  same  as  before, 
with  perhaps  a  little  increased  tension.  The  walls  of  the 
radials  are  distinctly  thickened.  When  the  albumen  was 
present  there  was  always,  he  says,  some  intermission  of  pulse, 
but  this  has  continued  during  the  last  year  although  the 
albumen  has  been  absent. 

By  way  of  treatment,  various  plans  were  tried.  Arsenic 
failed  entirely.  Iron  produced  little  benefit.  Spinal  douches 
of  cold  water  falling  from  a  height  of  eight  feet  did  much 
good  ;  while  cold  sitz  and  Turkish  baths  (without  the  cold 
douche)  increased  the  albuminuria.  If,  however,  he  took 
either  a  Turkish  or  a  cold  sitz  bath  in  the  morning  when  he 
had  no  albuminuria,  neither  of  them  produced  it.  But,  on 
the  whole,  nothing  proved  so  serviceable  as  the  combination 
of  iron  with  chloride  of  ammonium. 

Summing  up  the  facts  ascertained  in  this  case  we  find — 

1 .  That  albuminuria  occurred  only  after  ingestion  of  food. 

2.  That  it  occurred  in  summer  and  at  certain  periods  of 
the  day — viz. ,  after  breakfast  and  after  the  midday  meal ; 
never  before  breakfast  or  in  the  evening. 

3.  That  its  onset  was  sudden,  setting  in  as  soon  as  food 
reached  the  stomach. 

4.  That  the  nature  of  the  diet  appeared  to  have  little  or 
no  effect. 


DIETETIC    ALBUMINURIA CASES.  149 

5.  That  exercise  bad  a  decided  effect,  but  only  secondary 
to  that  of  food. 

6.  That  the  albuminuria  was  worse  after  mental  excite- 
ment. 

7.  That  cold  douches  applied  to  the  spine  checked  it. 

8.  That  counter-irritation  to  the  loins  by  mustard  or 
croton  oil  did  not  at  all  diminish  the  albuminuria,  but  rather 
increased  it. 

9.  That,  as  regards  medicines,  arsenic  had  no  effect,  and 
while  iron  proved  slightly  beneficial,  iron  with  chloride  of 
ammonium  was  much  more  efficient. 

The  first  question  which  arose  as  to  diagnosis  in  this  case 
was  whether  Bright's  disease  existed  or  not.  The  state  of 
the  vessels,  in  respect  both  of  their  walls  and  tension,  might 
have  corresponded  to  this,  and  the  heart's  action  was  such 
as  one  sees  occasionally  in  renal  cases.  But  there  had  never 
been  a  trace  of  dropsy,  there  were  no  tube  casts,  the  specific 
gravity  was  good,  and  the  albuminuria  came  and  went. 
Therefore,  there  was  manifestly  no  inflammation  of  the 
tubules.  The  quantity  of  the  urine,  the  specific  gravity,  and 
the  absence  of  consequent  complications,  such  as  the  retinal 
changes,  excluded  a  diagnosis  of  cirrhosis,  while  there  was 
no  polyuria,  or  any  causal  or  concomitant  complications  fitted 
to  suggest  waxy  disease.  It  was  also  certain  that  the 
albuminuria  was  not  an  accidental  result  of  disease  of  the 
urinary  tract.  I  therefore  concluded  that  it  belonged  to  the 
category  of  unimportant  albuminurias  and  gave  from  the  first 
a  correspondingly  favourable  prognosis.  It  was  only  later 
that  all  the  facts  which  I  have  mentioned  became  known 
to  me,  and  now,  surveying  them,  it  is  clear  that  we  have  to 
do  with  a  form  of  albuminuria  referable  to  the  functional 
group,  being  related  to  the  ingestion  of  food,  influenced 
in  an  important  measure  by  season  and  time  of  day,  but  also 
markedly,  though  in  a  minor  degree,  to  exercise. 


150  ALBUMINURIA. 

Deferring  what  I  have  to  say  regarding  the  causation  of 
dietetic  albuminuria,  I  must  express  the  wish  that  I  could 
throw  definite  light  upon  the  curious  annual  and  daily  cycle 
observed  in  this  case — not  a  cycle  of  albuminuria,  but  a 
cycle  of  capacity  for  dietetic  albuminuria.  With  our  present 
knowledge,  speculation  on  this  subject  is,  however,  not 
profitable. 

This  patient's  constitution  is  peculiar,  combining  a  marked 
nervous  excitability  with  a  tendency  to  hepatic  derangement. 
He  is  liable  to  mental  depression — often  suffers  from  what 
he  calls  an  ill- defined  dread.  His  complexion  is  sallow, 
especially  during  what  he  terms  his  bilious  attacks.  These 
are  attended  by  general  malaise,  headache,  catarrh  of  stomach, 
irregularity  of  bowels,  and  functional  disturbance  of  the  liver. 
He  is  greatly  impressed  with  the  value  of  chloride  of 
ammonium  in  the  treatment,  not  only  of  his  renal,  but  also 
of  his  nervous  symptoms  and  his  digestive  disorders. 

In  order,  then,  to  clear  up  the  diagnosis  in  a  case  of 
supposed  dietetic  albuminuria,  it  is  necessary  to  experiment 
with  various  articles  of  diet,  and  watch  the  result. 

What  explanation  can  we  offer  of  this  form  of  albuminuria  ? 
Obviously  it  cannot  be  due  to  primary  change  in  the  secret- 
ing tissue,  for,  although  albumen  may  be  very  copious,  there 
is  no  discharge  of  tube  casts  or  renal  epithelium.  A 
chemical  alteration  of  the  albumen  of  the  blood,  or  of  its 
condition  in  other  respects,  naturally  suggests  itself.  In 
regard  to  the  first  of  these  suppositions,  one  can  understand 
how,  with  faulty  chemical  processes  within  the  body,  diges- 
tion of  nutritive  substances  and  transformations  of  albumen 
might  be  abnormally  performed,  and  albumens  more  capable 
of  transudation  produced,  but  I  know  of  no  sufficient  evidence 
of  the  real  existence  of  such  a  process.  The  excretion  of 
more  diffusible  forms  of  albumen,  such  as  propeptone  and 
peptone,  is,  of  course,  known  to  be  of  not  infrequent  occur- 


DIETETIC    ALBUMINURIA — CASES.  151 

rence,  and  it  may,  in  some  cases,  be  related  to  digestion,  but  at 
present  we  are  studying  cases  in  which  the  ordinary  forms  of 
albumen — serum  albumen  and  serum  globulin — are  met  with. 

Apart,  however,  from  any  such  problematic  change  in  the 
nature  of  the  albuminous  constituents  of  the  blood,  we  have 
to  consider  another  possible  explanation.  It  is  definitely 
known  that  changes  in  some  of  the  other  blood  elements 
exert  a  marked  influence  upon  the  filtration  of  the  ordinary 
forms  of  albumen.  We  have  seen  that  the  quantity  of 
albumen  which  passes  through  a  filter  increases  with  the 
increase  of  the  saline  constituents.  Chloride  of  sodium  is 
the  most  efficacious,  but  nitre,  chloride  of  calcium,  and  even 
urea  exert  a  certain  influence.  We  can  readily  conceive 
that,  after  a  meal,  the  salts  of  the  blood  may  be  increased  ; 
it  seems  possible  that  in  this  way  transudation  of  the 
albumen  may  be  induced.  The  whole  question  of  the 
influence  of  salts  on  the  circulation  is  very  interesting.  If 
you  attempt  to  pass  fluids  of  various  kinds  through  the 
vascular  system  of  the  kidneys  of  animals  recently  killed, 
you  will  find  that  it  is  much  easier  to  pass  one  rich  in  salts 
than  simple  water.  But  to  this  subject  I  have  already 
alluded,  and  I  would  say,  meanwhile,  that,  although  the 
fact  as  to  diffusion  is  well  established,  its  applicability  in  the 
explanation  of  such  cases  as  those  we  are  considering  is  not 
yet  demonstrated. 

While,  however,  giving  these  suggestions  towards  chemical 
explanations  due  weight,  I  cannot  but  advert  to  the  possi- 
bility of  reflex  vascular  influence  being  at  work.  We  may 
conceive  that,  on  the  entrance  of  food  into  the  stomach,  the 
terminations  of  the  vagi  may  be  morbidly  influenced,  or  that 
the  nerves  supplying  the  renal  vessels  respond  abnormally  to 
a  normal  peripheral  impression.  I  have  already  accentuated 
the  fact  that  the  patient,  whose  case  I  have  last  described, 
says  that  as  soon  as  food  reaches  his  stomach  the  albumen 


152  ALBUMINUKIA. 

appears,  and  that  the  nature  of  the  food  ingested  makes  no 
difference.  One  can  scarcely  suppose  that  sufficient  time  has 
elapsed  for  absorption,  chemical  alterations,  and  excretion, 
and  it  seems  reasonable  to  suspect  that  an  influence  exerted 
on  the  vessels  through  the  nervous  system  would  have  more 
chance  of  bringing  about  the  result  within  the  time.  While 
throwing  out  these  suggestions,  I  must  admit  that  our 
present  knowledge  does  not  suffice  to  afford  a  satisfactory 
explanation. 

III.  I  shall  now  illustrate  albuminuria  following  upon 
muscular  exertion,  and  shall  bring  out  its  features  by  narrat- 
ing a  case  at  present  (July,  1886)  under  my  care.  The 
patient  is  a  girl  thirteen  years  old.  I  show  you  a  sample  of 
her  urine,  passed  on  rising  at  7.30  a.m.  When  I  test  it 
with  nitric  acid  you  see  that  it  contains  no  albumen,  or  only 
the  very  faintest  trace.  But  this  specimen,  which  was  passed 
an  hour  later,  after  dressing  and  moving  about  the  house,  but 
before  any  food  had  been  taken,  is,  as  you  see,  highly  albu- 
minous. Thus  the  getting  up  is  followed  by  this  extraordi- 
nary and  marked  albuminuria.  The  history  of  the  case  is 
as  follows  : — Her  previous  health  is  reported  to  have  been 
good.  About  last  Christmas,  while  at  a  boarding-school,  she 
had  an  attack  of  diphtheria,  which  is,  like  scarlatina,  a  not 
uncommon  cause  of  albuminuria  by  the  production  of  inflam- 
matory Bright's  disease.  She  did  well,  however,  and  went 
through  the  whole  illness  without  a  trace  of  albumen  appear- 
ing in  the  urine.  I  can  say  so  with  confidence,  as  I  know 
that  particular  care  was  taken  in  regard  to  its  examination. 
When,  however,  she  was  convalescent,  and  was  getting  up 
and  going  about  the  house  (but  not  getting  out),  albumen 
was  detected.  This  does  not  correspond  to  the  ordinary 
clinical  history  of  albuminuria  connected  with  diphtheria. 
As  a  rule,  it  appears  during  the  attack,  or  on  exposure  to 
cold,  within  a  few  days  of  its  subsidence.      My  own  experi- 


ALBUMINURIA    FROM    MUSCULAR    EXERTION CASE.      153 

ence  in  this  matter  corresponds  with  that  of  others.  Dr. 
John  Abercrombie,(112)  for  example,  says  that  while  he  has  seen 
it  occur  within  twenty-four  hours  of  the  first  symptoms  of 
diphtheria,  he  has  never  seen  it  commence  later  than  the 
tenth  day  of  the  disease.  During  January,  a  few  tube  casts 
were  found  on  two  occasions,  and  sugar  was  present  once  or 
twice  in  small  quantity.  At  first  no  peculiarity  was  observed 
as  to  the  albuminuria,  and  so  it  was  of  course  believed  to  be 
constant,  and  regarded  as  a  result  of  renal  disease  due  to 
diphtheria.  It  was  only  after  some  considerable  time  that  it 
was  discovered  that  the  urine  passed  on  getting  up  in  the  morn- 
ing, and  also  that  passed  during  the  night,  contained  no  albu- 
men. This  fact  was  noticed  the  first  time  the  urine  of  these 
periods  of  the  day  was  separately  tested,  and  from  inquiry  I  find 
that,  although  the  peculiar  periodicity  was  only  then  observed, 
it  may  have  existed  from  the  first,  and  I  think  the  history  and 
progress  of  the  case  make  it  most  probable,  in  fact  almost 
certain,  that  it  did  so.  I  have  said  that  traces  of  sugar  were 
sometimes  discovered  in  the  early  period  of  the  illness.  No 
trace  of  it  has  ever  been  detected  since  the  patient  came 
under  my  care,  nor  have  there  been  any  casts.  In  a  speci- 
men passed  on  rising,  however,  we  found  one  morning  a 
well-marked  layer  of  oxalates  deposited  on  the  top  of  the 
mucus,  and  under  the  microscope  octahedral  crystals  of 
oxalate  of  lime  were  seen  in  very  large  numbers.  Curiously, 
in  a  specimen  passed  an  hour  later,  there  was  not  a  single 
oxalate  crystal ;  the  urine  had  become  alkaline,  and  there 
was  a  pretty  copious  deposit  of  triple  phosphates. 

This  patient  has  now  been  for  a  considerable  time  under 
my  observation,  and  I  can  give  some  interesting  details  as  to 
the  features  of  her  albuminuria  and  as  to  some  experiments 
which  we  have  made  regarding  it.  I  have  already  pointed  out 
that  the  urine  passed  on  rising — and  the  same  has  been 
true,  except  on  one  or  two  occasions,  of  that  passed  during 


154  ALBUMINURIA. 

the  night — contains  no  albumen,  or  only  the  merest  trace. 
Now  while  she  is  up  the  albumen  is  constant,  though  once 
or  twice  toward  evening  the  quantity  has  been  small.  But 
the  fact  as  to  the  daily  cycle  of  the  albuminuria  is,  that  the 
quantity  is,  as  a  rule,  largest  in  the  morning  in  the  urine 
passed  before  breakfast.  I  have  many  times  examined 
samples  passed  forty-five  minutes  after  she  got  up  and  before 
she  had  taken  any  food,  and  have  found  the  albumen  in 
them  to  be  very  copious.  It  would  appear,  therefore,  that 
the  moment  she  gets  up  there  is  a  sudden  onset  of  albumin- 
uria, so  that  this  case  forms,  in  this  respect,  an  interesting 
parallel  to  that  which  I  have  described  in  the  dietetic  group, 
in  respect  to  suddenness  of  onset,  although  due  to  a  different 
cause.  During  the  forenoon  the  albumen  has  several  times 
been  observed  to  become  distinctly  diminished  in  amount. 
Sometimes,  though  not  so  often,  it  is  in  largest  quantity 
later  in  the  day — during  the  afternoon  or  the  earlier  part 
of  the  evening. 

I  have  further  tested  the  conditions  of  the  albuminuria  by 
experiment.  On  one  occasion  she  remained  in  bed  a  whole 
day  and  two  nights — about  thirty-six  consecutive  hours,  tak- 
ing her  ordinary  diet  during  the  time.  The  result  was  that 
the  albumen  scarcely  appeared.  Indeed,  there  was  in  only 
one  of  the  samples  passed  during  that  period  anything  more 
than  a  mere  trace,  and  in  that  sample  the  quantity  was  small. 
Curiously,  in  the  urine  passed  at  night  after  she  had  been  all 
day  in  bed,  albumen  appeared  in  small  quantity.  In  that 
passed  in  the  morning  there  was  a  mere  trace.  She  then  got 
up,  and  in  the  urine  passed  forty-five  minutes  after,  the  albu- 
men was  found  to  be  present  in  large  quantity, — distinctly 
larger  than  it  had  usually  been  before.  It  was  again  present 
in  small  quantity  the  following  night,  and  there  was  a  distinct 
trace  on  rising  the  next  morning.  After  that,  the  former 
cycle  became  re-established.     Thus  the  rest  in  bed,  though  it 


ALBUMINURIA    FROM    MUSCULAR    EXERTION.  155 

greatly  diminished,  did  not  entirely  prevent  the  albuminuria  ; 
and  it  was  followed  by  an  increased  elimination  of  albumen 
when  she  got  up,  and  a  disturbance  of  the  ordinary  diurnal 
cycle.  A  corresponding  result  was  elicited  when  the  same 
experiment  was  repeated. 

On  another  occasion  an  experiment  of  an  opposite  kind 
was  made.  She  was  asked  to  rise  at  5  a.m.,  dress,  and  walk 
about  the  house  for  three-quarters  of  an  hour.  The  urine 
passed  on  rising  was  free  from  albumen,  whereas  that  passed 
forty-five  minutes  later  contained  abundance  of  it.  She  then 
lay  in  bed  till  7  A.M.,  and  the  urine  passed  at  that  time  con- 
tained no  albumen  or  only  a  mere  trace.  She  got  up,  and 
by  7.45  the  albumen  was  again  abundant. 

On  another  morning  she  was  asked  to  lie  in  bed  and  to 
move  about  the  arms  and  legs,  thus  taking  exercise  in  the 
recumbent  posture.  This  she  did  for  twenty  minutes,  and 
the  astonishing  result  was  that  the  urine  passed  after  the 
time  of  exertion  was,  like  that  passed  before  it,  perfectly  free 
from  albumen. 

The  next  morning  she  was  subjected  for  twenty  minutes  to 
very  efficient  massage  in  bed,  but  neither  before  nor  after  it 
did  albumen  appear. 

A  warm  bath  proved  equally  inoperative.  Experiments 
were  also  tried  with  different  kinds  of  diet,  and  they  turned 
out  to  have  very  little  effect.  She  was  fed  for  several  days 
exclusively  on  milk.  It  produced  marked  diuresis,  and 
so,  the  urine  being  increased,  the  albumen  seemed  diminished, 
but  the  diminution  was  merely  relative,  not  absolute.  The 
subsequent  addition  of  an  egg  daily  and  some  bread  and 
butter  to  the  diet  did  not  produce  any  evident  increase  in  the 
albumen.  Nor  did  it  increase  when  ordinary  or  even  rich 
diet  was  prescribed. 

I  have  put  in  a  tabular  form,  on  page  157,  the  most 
important  points  connected  with  the  urine  in  this  case.      The 


156  ALBUMINURIA. 

first  table  shows  the  patient's  usual  cycle,  the  second  the 
cycle  as  influenced  by  experiment.  From  these  experiments 
it  is  obvious  that  the  change  from  the  recumbent  to  the 
erect  posture  is  at  least  the  main  factor  in  the  production  of 
the  albuminuria,  remarkable  as  that  may  appear.  Diet  has 
only  a  very  slight  effect,  and  the  condition  contrasts  strik- 
ingly with  that  seen  in  the  dietetic  case  which  I  have 
described.  This  case  also  differs  from  most  if  not  all  the  so- 
called  cyclic  cases  which  I  have  seen  recorded,  in  respect  of 
the  suddenness  of  the  onset  of  the  albuminuria.  In  them  it 
commenced,  as  a  rule,  gradually  and  increased  during  the 
earlier  part  of  the  day,  and  then  gradually  diminished  toward 
night,  flowing  and  ebbing  like  the  quiet  tide,  whereas  in  our 
case,  though  the  diminution  is  gradual,  the  onset  is  sudden 
and  abrupt  like  the  tidal  wave  which  is  seen  in  certain  rivers. 

I  have  now  related  most  of  the  facts  of  the  case,  and  will 
next  discuss  the  question,  What  is  the  nature  of  the  albu- 
minuria from  which  she  suffers  ?  Is  this  young  lady  affected 
with,  as  was  at  first  assumed,  a  hopeless,  chronic  renal 
disease  which  must  almost  inevitably  send  her  to  her  grave 
before  she  is  twenty,  or  has  she  merely  an  unimportant  albu- 
minuria without  organic  disease,  which  may,  perhaps,  dis- 
appear when  she  gets  past  her  present  critical  period  of  life, 
and  at  all  events  gives  no  ground  for  anxiety  ?  From  a 
careful  study  of  the  case,  I  am  convinced  that  the  latter  is 
the  correct  diagnosis.  The  grounds  upon  which  I  have 
formed  this  opinion  are  : 

1st.  That  there  is  a  period  in  every  day  in  which  the 
urine  is  free  from  albumen ; 

2nd.  That  the  quantity  of  urine  and  of  urea  is  normal ; 

3rd.  That  except  on  two  occasions  no  tube  casts  have 
ever  been  found  ;  and, 

4th.  That  there  is  no  symptom  except  the  albuminuria  at 
all  fitted  to  suggest  the  idea  of  organic  renal  disease. 


ALBUMINURIA    FROM    MUSCULAR    EXERTION. 


157 


Table  XXYI. — Report  of  Examinations  op  Urine  in  Case  op  Albumin- 
uria from  Exercise,  beginning  with  20th  June,  1886. 


Albumen. 

Quantitative 

Percentage 

Specific 

Reaction. 

estimation  by 

of  Bile  Salts 

Urea  in 

Gravity. 

Dr.  Oliver's 

normal = 

Grains. 

Percentage 

100  per  cent. 

Method. 

June  20th. 

7.45  A.M.,       .... 

1023 

Distinctly 
acid. 

Trace. 

240  or  200 

110-6310 

8.50  A.m.    Before  breakfast, 

1013 

Faintly 
alkaline. 

0'133  per  cent. 

300+ 

2-757 

10.30  A.M.    An     hour    after 

(Below 

Slightly 

Less  than 

300 

17-89426 

breakfast. 

average.) 

alkaline. 

O'Oo  per  cent. 

6.30  p.m.    After  dinner  and 

1029 

Faintly 

013  per  cent. 

240 

38-67 

tea. 

acid. 

9  p.m.         Going  to  bed, 
Total,      .... 
June  21st. 

1026 

Decidedly 
acid. 

0'08  per  cent. 

150 

66-102 

236-0548 

Night, 

1011 

Distinctly 
acid. 

Trace. 

100 

58'93674 

7  a.m., 

1016-5 

Acid. 

Very  slight 
trace. 

166 

64  8 

10.30  A.M 

1017 

Very  faintly 
acid. 

0  24  percent. 

300 

24-25 

Neither  sugar,  peptones,  nor  bile  pigment  present  in  any  of  the  specimens. 

Table  XXVII. — Urine  before,  during,  and  after  the  Experiment  of 

RISING  AT  5  A.M.,  GOING  TO  BED  AGAIN  AT  5.45,  AND  RISING  AGAIN  AT  7  A.M. 


Specific 
Gravity. 

Reaction. 

Albumen. 

Quantitative 

estimation  by 

Dr.  Oliver's 

Percentage 

Method. 

Percentage 
of  Bile  Salts 

normal= 
100  percent. 

Urea  in 
Grains. 

June  22nd. 
9  P.M., 

June  23rd. 

5  A.M., 

5.45  A.M.    Arose  at  5  A.M.,    . 
7  A.M.         In  bed  since  5.45, . 
7.45  A.M.    Up  since  7  A.M. ,    . 
2.30  p.m.,        .... 
9  p.m.         Going  to  bed, 

Total,     .        .        .        • 
June  29th. 

7  A.M., 

7.45  a.m.    Still  in  bed,  before 
breakfast. 

1027 

1020 
1019 

9 

1013 
1009 
1023 
1027 

1012 
1024 

1024 

Acid. 

Slightly 
acid. 
Acid. 

Acid. 

Acid. 

Neutral. 

Slightly 
acid. 

Strongly 
acid. 

Acid. 
Acid. 
Acid. 

0'08  per  cent. 

Faint  trace. 

Almost  imper- 
ceptible. 
0'05  per  cent. 

Scarcely  per- 
ceptible. 
0-06  per  cent. 

0-3  per  cent. 

0-16  per  cent. 

Faint  trace. 

Very  faint 

trace. 
Very  faint 

trace. 

240 

166  or  less. 

166 

300 
240  or  200 

183  (?) 

200 

183 

150 
240  or  200 

300 

69-267 

72  5933 
29-388 

5-6038 
17-04713 

4-4361 
41-40092 
81-13725 

251-60659 

99-2715 

36-1269 

6-6111 

No  sugar,  peptones,  or  bile  pigment  in  any  of  the  specimens. 


158  ALBUMINURIA. 

I  shall  now  recur  to  the  case  of  the  gentleman  regarding 
whom   I   have  already  given  some  details.     The  patient  is 
between  twenty  and   thirty,  and  has  travelled  very  exten- 
sively,   riding    and    walking   a   great    deal.       The    earliest 
symptom  of  which  he  complained  was  a  painful  uneasiness 
in   the  calves   of  his   legs.     The   most  careful  examination 
afforded  no  evidence  of  disease  in  any  part  of  the  body,  some 
degree  of  dilatation  of  the  stomach  and  the  abnormality  of 
the  urine  alone  excepted.     On  5th  June,  1885,  I  examined 
six  specimens  of  his  water.     At  7.30  p.m.  the  albumen  was 
copious  ;  at   8.50  it  was  very  distinct ;  at  9.30  a.m.  there 
was  a  trace  ;   at  10.30  it  was  distinct ;  at  12.30,  the  patient 
having  in  the  meantime  taken  a  walk,  it  was  copious.    There 
were  no   tube   casts,  and   the  amount  of  urea  was  normal. 
A  few  days  later,  after  he  had  recovered  from  the  fatigue  of 
a  long  journey,  I  found  at  1.50,   3.40,   and   5.45    p.m.   no 
albumen  ;  at  7.30  a  trace  ;   at  8.30  a.m.  a  very  slight  trace  ; 
at  10  a.m.  a  slight  trace.     I  have  already  pointed  out  that 
diet,  even  of  a  rich,  varied,  and  ill-chosen  sort,  produced  no 
albuminuria.      On  the  other  hand,  walking,  especially  walk- 
ing up  hill,  always  did  so.      He  lived  in  a  hotel  in  Princes 
Street,  and  could  walk  to  Charlotte  Square  with  little  or  no 
effect  on  the  urine,  but  if  he  took  a  walk  to  the  Calton  Hill, 
the  Castle,  or  Arthur's  Seat,  the  albumen  became  copious. 
With    rest    it    gradually    disappeared.       Carriage    exercise 
seemed  to  produce  no  unfavourable  effects.     Massage,  which 
had  been  very  carefully  tried,  being  thoroughly  carried  out 
for  forty  or  fifty  minutes  by  a  most  competent  rubber,  was 
also  without  result.     I  tried  the  effect  of  exercise  in  a  sitting 
posture.      He  sat  in  his  chair  and  played  the  banjo  for  an 
hour,  and  then  used  dumb-bells  for  fifteen  minutes.     The 
urine  passed  immediately   afterward  was    normal,   but   that 
voided  half-an-hour  later   contained   albumen.       I  did  not 
think  of  trying  the  effect  of  muscular  movement  when  he 


ALBUMINURIA    FROM    MUSCULAR    EXERTION.  159 

was  lying  on  his  back.  It  was  however  abundantly  clear 
that  muscular  exertion,  and  particularly  active  walking 
exercise,  was  the  chief  exciting  cause  in  this  case  also, 
while  no  effect  was  produced  by  a  change  from  the  re- 
cumbent to  the  upright  position.  I  need  not  again  go  over 
the  reasons  which  led  me  in  this  case  also  to  give  a  favourable 
opinion. 

As  to  the  origin  of  the  symptom,  it  is  worth  noting  that 
in  his  travels  he  once  walked  through  Asia  Minor  in  a 
wonderfully  short  space  of  time,  and  it  was  during  or  after 
this  feat  that  the  albuminuria  was  first  observed.  It  is 
very  probable  that  the  great  strain  on  his  system  which  his 
feat  implied  was  the  starting-point  of  the  albuminuria,  which 
subsequently,  when  the  damage  had  been  done,  could  be 
induced  by  a  much  less  amount  of  exertion. 

Passing  from  the  illustrative  cases,  I  shall  now  direct 
attention  to  certain  special  points  of  interest  connected  with 
them  : 

1.  The  kind  of  albumen  discharged  has  recently  received 
some  attention.  Dr.  Maguire  (54)  has  published  the  results  of 
investigations  as  to  the  forms  of  albumen  met  with  in  differ- 
ent diseases,  and  he  concludes  that  the  less  grave  the  case 
the  greater  is  the  amount  of  paraglobulin  in  proportion  to 
the  amount  of  serum  albumen.  In  three  cases  of  cyclic 
albuminuria  he  found  that  the  albumen  present  entirely,  or 
almost  entirely,  consisted  of  paraglobulin.  In  a  case 
described  as  one  of  ansemia  with  albuminuria,  due  in  all 
probability  to  fatty  degeneration  of  the  kidney,  both  serum 
albumen  and  paraglobulin  were  present,  but  the  latter  was 
in  much  greater  quantity  than  the  former,  while  in  Bright' s 
disease  the  proportion  of  these  two  substances  was  reversed. 
On  examining  very  carefully  into  this  question,  in  the  case 
of  the  young  lady,  the  serum  albumen  was  found  to  be  in 
greater   quantity    than    the    paraglobulin,    and,    as    it    was 


160  ALBUMINURIA. 

certainly  functional,  I  cannot  admit  the  universality  of  Dr. 
Maguire's  conclusion. 

2.  Another  observation  as  to  the  kind  of  albumen  present 
has  been  made  by  Dr.  Pavy.  He  finds  that  sometimes  it  is 
not  ordinary  serum  albumen,  but  alkali-albumen.  I  am  not 
in  a  position  to  confirm  this  statement  from  my  own  observa- 
tions, but  I  have  been  struck  with  the  facility  and  rapidity 
of  formation  of  acid  albumen,  very  slight  quantities  of  acid 
sometimes  preventing  coagulation  by  heat. 

3.  No  peptones,  or  any  other  body  of  that  group  have 
been  found  in  our  case,  and  very  little  is  said  of  them  in 
cases  recorded  by  others.  I  observe,  however,  that  Dr. 
01iver,(113)  of  Harrogate,  has  met  with  an  instance  of  inter- 
mittent albuminuria,  in  which  peptones  replaced  the 
albumen  for  a  time. 

4.  My  patient,  though  she  had  no  distinct  oedema,  had  a 
pale,  puffy-looking  face.  This  was,  I  believe,  due  partly  to 
a  general  morbid  condition  of  the  vessel  walls,  and  partly  to 
the  ansemia  which  often  accompanies  this  affection. 

5.  Occasionally  sugar  is  found  instead  of  or  in  addition 
to  the  albumen.  It  was  detected  early  in  the  illness  by  good 
observers  in  both  the  cases  last  described  ;  and  this  fact,  as 
will  be  seen,  lends  support  to  the  hypothesis  that  faulty 
metabolism  may  have  to  do  with  the  production  of  the 
albuminuria  in  such  cases. 

6.  Other  chemical  changes  also  occur.  Thus  phosphates 
may  be  present  in  addition  to,  or  alternately  with,  the 
albumen.  Urates  are  sometimes  very  abundant,  and  some- 
times uric  acid  is  present  in  considerable  quantity.  The 
most  common  of  all  the  additional  chemical  abnormalities  is 
the  presence  of  oxalates.  They  occur,  at  least  occasionally, 
in  a  large  proportion — I  should  say  in  the  majority — of 
cases.  It  is  found  that  ordinary  oxaluria  sometimes  leads 
to   temporary  albuminuria  and  the  presence  of  tube  casts, 


ALBUMINURIA    FROM    MUSCULAR    EXERTION.  161 

probably  by  irritating  the  renal  tissues  ;  but,  in  addition,  it 
should  be  observed  that  oxalates  very  frequently  appear  in 
the  course  of  the  cases  we  are  considering. 

7.  The  bile  salts  have  been  found  present  in  very  con- 
siderable excess.  In  the  case  recorded  by  Dr.  Oliver,  to 
which  I  have  already  referred,  this  was  so.  In  one  of  my 
cases  also  they  were  present  in  marked  excess,  and  my 
friend,  Dr.  Stevens,  who  has  devoted  much  time  to  this 
subject,  drew  my  attention  to  the  fact  that  there  has  been  a 
diurnal  cycle  in  their  excretion  corresponding,  in  the  main, 
to  the  cyclic  character  of  the  albuminuria.  This  was  very 
distinctly  made  out  when  the  patient  was  on  ordinary  diet, 
and  nothing  was  done  to  disturb,  in  any  way,  her  daily 
routine  of  life.  The  urine  passed  at  night  usually  contained 
little  more  than  the  small  quantity  which  one  expects  to 
find  in  the  urine  of  healthy  individuals.  In  the  urine  passed 
on  rising  they  were  in  excess,  still  more  in  that  passed  before 
breakfast,  at  which  time  the  quantity  sometimes  reached  its 
maximum  for  the  twenty-four  hours.  The  amount,  as  a  rule, 
kept  up  during  the  day,  and  diminished  toward  evening. 
One  interesting  fact  thus  brought  out  is  that  the  excretion 
of  bile  salts  began  to  increase  during  the  morning  before 
rising,  so  that,  whereas  the  albuminuria  appeared  to  be 
due  to  exercise  in  the  upright  posture,  and  to  be  little 
influenced  by  anything  else,  the  excretion  of  the  bile  salts 
was  partly  influenced  by  exercise,  but  partly  dependent  on 
some  other  factor.  This  is  further  shown  by  the  circum- 
stance that  when  the  patient  was  kept  in  bed  for  thirty-six 
hours  the  diurnal  cycle  in  their  excretion  continued  to  be 
observed. 

I  may  further  state  that  a  diurnal  variation  has  been 
observed  by  Dr.  Oliver  in  the  secretion  of  the  bile  salts 
in  health,  and  his  result  may  be  broadly  stated  to  be  that 
the  quantity  increases  during  fasting  and  diminishes  during 

M 


162  ALBUMINURIA. 

digestion — falling  rapidly  after  meals.  But  in  this  patient's 
case  this  is  entirely  altered.  The  night  urine,  during 
fasting,  contains  the  smallest  quantity  of  all.  No  doubt  it 
increases  toward  morning,  and  still  more  when  she  rises 
before  breakfast  ;  but  then  the  quantity  keeps  up  during  the 
day  while  digestion  is  going  on,  and  only  falls  again  toward 
night.  A  similar  change  was  observed  by  Dr.  Oliver.  He 
found  that  when  albuminuria  occurred  after  a  meal  the  bile 
salts  were  excreted  in  increased  quantity,  whereas  if  at  any 
time  albuminuria  did  not  occur  after  a  meal,  the  excretion 
of  bile  salts  was  within  the  normal  range.  It  will  be 
observed  that  Dr.  Oliver  found  this  change  in  the  discharge 
both  of  albumen  and  of  bile  salts  to  stand  in  relation  to  the 
diet,  whereas  in  our  case  it  is  related  to  exercise.  The  two 
cases  are,  therefore,  not  similar,  the  one  being  an  albumin- 
uria from  exercise,  the  other,  as  stated  by  Dr.  Oliver,  being 
of  hepatic  origin.  We  have  in  this  altered  excretion  of  the 
bile  salts  an  indication  of  some  morbid  chaDge  in  the 
chemical  or  absorptive  processes  which  I  shall  discuss  later 
on.# 

*  Until  recently  our  only  method  of  detecting  the  bile  salts  in  the  urine 
was  that  of  Pettenkofer  by  sugar  and  sulphuric  acid.  This  method,  how- 
ever, owing  to  the  necessity  of  first  extracting  the  bile  salts  from  the 
urine,  though  it  might  be  satisfactory  in  the  hands  of  chemists,  was 
impracticable  as  a  clinical  test.  Dr.  Oliver,0"  of  Harrogate,  has  devised  a 
method  free  from  this  objection,  and  by  which  a  quantitative  estimate 
can  be  made.  It  depends  on  the  fact  that  the  bile  salts  precipitate 
albumen  or  peptone  when  the  fluid  is  of  the  requisite  degree  of  acidity, 
and  the  test  is  done  in  specially  graduated  tubes  with  a  standard  solution 
of  peptone  acidified  to  the  proper  degree  by  acetic  acid.  The  solution  is, 
however,  difficult  to  prepare,  and,  if  much  used,  comes  to  be  expensive. 
A  simpler  qualitative  method,  depending  on  the  same  property  of  the  bile 
salts,  but  requiring  no  special  reagent,  was  devised  by  Dr.  Stevens  (Ettles 
Scholar  for  1884,  and  at  present  one  of  my  assistants,  in  the  course  of  his 
clinical  work  as  holder  of  the  Stark  Scholarship  in  Clinical  Medicine). 
The  urine,  if  not  albuminous,  must  first  have  a  little  albumen  added  to  it. 
An  albuminous  urine  does  very  well  for  this — care  being  taken  that  one  is 
selected  which  does  not  itself  contain  any  excess  of  bile  salts.   A  few  ounces 


ALBUMINURIA    FROM    MUSCULAR    EXERTION.  163 

8.  The  presence  of  a  normal  amount  of  urea  and  the 
general  absence  of  tube  casts  are  specially  worthy  of  our 
notice. 

We  have  now  to  ask  ourselves  what  explanation  our  pre- 
sent knowledge  enables  us  to  give  of  the  cases  of  this  class. 
While  it  must  be  at  once  conceded  that  changes  of  a  gross 
kind  in  the  secreting  renal  tissues  are  not  very  probable,  it 
might  be  held  that  molecular  alterations  of  the  cells  in  the 
Malpighian  tufts  dependent  upon  congenital  peculiarities 
might  exist,  permitting  the  transudation  of  albumen  along 
with  the  water  of  the  blood  serum.  But  I  am  not  aware  of 
any  sufficient  evidence  in  favour  of  such  a  view,  and  the 
conditions  under  which  the  albumen  appears  seem  suscep- 
tible of  a  better  explanation.     There  are  some  considerations 

of  albuminous  urine  can  be  carbolised  and  kept  just  like  other  test  solu- 
tions for  any  length  of  time.  If  now  the  urine  be  poured  into  a  conical 
glass  and  a  little  cold  nitric  acid  be  run  carefully  down  the  side,  there  will 
be,  if  bile  salts  are  present  in  sufficient  quantity,  a  precipitate  of  albumen 
at  a  certain  level  in  the  urine,  separated  by  a  clear  area  from  the  precipi- 
tate of  albumen  produced  by  the  nitric  acid.  This  upper  precipitate  of 
albumen  is  produced  by  the  bile  salts  at  the  level  at  which  the  urine  has 
become  acidified  to  the  proper  degree.  A  slight  reaction  may  occur  even 
with  the  small  quantity  of  bile  salts  present  in  normal  urine,  and  a  similar 
faint  precipitate  may  also  be  seen  in  healthy  urine  owing  to  the  precipita- 
tion of  mucin  by  the  nitric  acid.  A  little  practice,  will,  however,  soon 
enable  you  to  distinguish  the  slight  precipitate  which  may  occur  in  health 
from  the  well-marked  and  dense  precipitate  which  appears  when  the  bile 
salts  are  present  in  excess.  It  is,  of  course,  necessary  to  avoid  mistaking 
a  precipitatiou  of  urates  by  the  nitric  acid  for  this  reaction  ;  should  there 
be  any  doubt,  the  effect  of  heat  will  set  it  at  rest.  As  the  test  is  simple  and 
easily  worked,  and  requires  no  special  reagent,  it  is  well  fitted  for  ordinary 
clinical  work.  Another  method  of  testing  the  bile  acids  has  been  intro- 
duced by  Prof.  Matthew  Hay  of  Aberdeen,  founded  upon  the  discovery  that 
when  bile  acids  are  present  in  urine,  the  surface  tension  is  lowered.  It 
consists  in  gently  dropping  a  little  sulphur  on  the  top  of  the  water.  In 
normal  conditions  it  remains  on  the  top,  when  bile  acids  are  present  it 
sinks  rapidly.  Dr.  Stevens  found  that  in  consequence  of  the  diminished 
surface  tension  the  drops  discharged  from  a.  pipette  are  smaller,  and  he 
finds  that  by  thus  counting  the  drops  from  a  given  quantity  of  urine  taken 
up  in  a  pipette,  he  can  pretty  accurately  gauge  the  proportion  of  bile  acids. 


164  ALBUMINURIA. 

which  favour  the  supposition  that  chemical  changes  in  the 
serum  may  be  the  cause — namely,  the  occasional  coexistence 
of  other  morbid  states  of  urine,  such  as  glycosuria,  phos- 
phaturia,  or  oxaluria.  Manifestly  no  change  in  blood 
pressure  within  the  kidney  or  in  the  walls  of  the  vessels, 
and  no  changes  in  renal  epithelium  could  account  for 
these,  and  it  seems  necessary  to  conclude  either  that  the 
albuminuria  and  they  are  common  manifestations  of  a  faulty 
metabolism,  or  that,  independently  of  alteration  in  the  kidney 
inducing  the  one,  we  have  alterations  in  the  liver  or  other 
organs  setting  up  the  others.  The  other  possible  cause  of 
the  albuminuria,  namely,  vascular  changes,  seems  to  corre- 
spond most  readily  with  the  facts  observed.  The  marked 
influence  of  muscular  exercise  and  exercise  of  particular  kinds, 
and  in  particular  postures,  does  not  seem  readily  explicable 
on  the  chemical  hypothesis,  while  what  we  know  of  the 
physiology  of  the  blood-vessels  prepares  us  to  believe  that 
alterations  of  their  lumen  and  of  the  blood  pressure  within 
them  might  readily  be  induced  under  such  circumstances,  and 
result  in  the  symptom  in  question.  The  occasional  occur- 
rence of  glycosuria  and  the  excess  of  bile  salts  might  be 
advanced  as  difficulties  in  the  way  of  this  explanation,  but  it 
is  easy  to  conceive  that  a  general  change  in  vascular  activity 
which  in  the  kidney  induces  albuminuria,  might,  by  its 
influence  on  the  liver,  induce  the  other  abnormalities.  My 
judgment,  therefore,  leans  toward  this  hypothesis,  but  I  can- 
not give  positive  proof  of  its  correctness. 

IV.  I  now  proceed  to  consider  much  more  briefly  the  fourth 
category  of  cases — those  of  Simple  Persistent  Albuminuria. 
I  cannot  speak  so  positively  and  definitely  in  regard  to  them, 
for,  on  the  one  hand,  they  are  certainly  rare,  and  on  the 
other,  they  are  difficult  to  differentiate  from  examples  of 
slight  chronic  organic  renal  disease;  still  our  conception  of 
this  subject  would  be  incomplete  if  we  did  not  refer  to  them. 


SIMPLE    PERSISTENT    ALBUMINURIA.  1G5 

I  can  recall  the  case  of  a  student  whom  I  watched  all 
through  his  University  career.  He  looked  quite  healthy. 
No  casts  were  ever  found  in  his  urine  and  the  albuminuria 
was  only  accidentally  discovered.  He  never  had  any  bad 
symptom.  He  successfully  went  through  the  arduous  work  of 
a  four  years'  course  in  medicine,  which  may  be  taken  as  a 
sufficient  guarantee  that,  despite  the  albuminuria,  his  health 
was  not  in  any  way  seriously  impaired.  I  cannot  be  certain 
that  he  had  no  intermissions,  but  I  do  not  think  he 
had. 

I  have  at  present  under  my  care  a  gentleman  whose  case 
probably  is  referable  to  this  category.  He  has  persistent 
slight  albuminuria,  none  of  the  many  specimens  passed  at  all 
hours  having  ever  been  found  free  from  albumen.  But  he 
has  no  tube  casts  and  he  discharges  a  normal  quantity  of 
urea.  The  albumen  is  scarcely  influenced  by  diet  or  exercise, 
although,  as  is  so  often  seen  in  all  albuminurias,  it  is  least 
abundant  during  the  night  and  early  morning.  There  is  no 
distinct  increase  of  vascular  tension  and  no  cardiac  hyper- 
trophy or  other  consequent  complication  of  renal  change. 
The  only  competing  diagnosis  is  slight  irritation  of  the 
urinary  tract,  due  to  an  old  gonorrhoea  from  which  he  for- 
merly suffered.  But  as  there  is  no  positive  evidence  of  this, 
I  incline  to  think  that  a  simple  persistent  albuminuria  is  the 
most  likely  cause. 

I  shall  now  record  a  case  which  I  believe  to  be  a  well- 
marked  example  of  this  form  of  albuminuria.  The  patient 
is  a  medical  man  in  active  practice,  who  consulted  me  in 
October,  1886,  regarding  the  state  of  his  health.  He  had  for 
some  time  previously  had  enlargement  of  the  cervical  glands, 
and  one  or  two  of  them  had  threatened  to  suppurate.  By 
the  time  he  consulted  me,  however,  some  improvement  had 
occurred  in  the  state  of  the  glands,  and  suppuration  seemed 
less  likely  to  result.      There  was  nothing  in  his  condition  to 


166  ALBUMINURIA. 

suggest  any  renal  abnormality  ;  but  on  examining  the  urine 
I  found  that  it  contained  a  considerable  quantity  of  albumen. 
I  then  decided  to  have  a  very  careful  investigation  on  this 
point  made,  and  for  that  purpose  asked  him  to  send  me 
separately  the  urine  of  each  micturition  for  a  period  of  twenty- 
four  hours.  I  received  from  him  samples  passed  on  19th  Oct., 
at  9.30  A.M.  on  rising,  and  at  1,  4,  7,  and  9  p.m.,  and  on 
20th  Oct.  at  1  and  4  A.M.,  and  at  8.45  am.  on  rising.  All  the 
specimens  were  albuminous,  but  the  albuminuria  was  not  so 
copious  as  it  had  been  when  he  consulted  me.  The  urine 
was  normal  in  colour.  The  mixed  urine  of  twenty-four  hours 
measured  64  ounces,  had  a  specific  gravity  of  1025,  and  was 
of  acid  reaction.  The  discharge  of  urea  in  twenty-four  hours 
amounted  to  617  grains.  No  sugar  or  peptone  was  present. 
Microscopically  there  were  found  one  or  two  hyaline  casts 
and  mucus  corpuscles.  The  urine  was  carefully  examined 
several  times  after  this,  and  it  always  presented  the  following 
characters : — The  quantity  was  rather  above  the  normal 
average  ;  the  specific  gravity  was  high ;  the  reaction  was  dis- 
tinctly acid  ;  albumen  was  constantly  present  ;  no  sugar, 
peptone,  or  bile  pigment  was  ever  found ;  the  amount  of  urea 
was  above  the  normal  average  ;  a  few  hyaline  casts  could,  as 
a  rule,  be  detected. 

It  was  sometimes  observed  that  the  colour  reaction,  pro- 
duced by  the  action  of  nitric  acid  on  the  urinary  pigment, 
was  decidedly  more  marked  than  in  normal  urines. 
Amorphous  urates  were  sometimes  copiously  precipitated,  and 
occasionally  uric  acid  crystals  were  present.  The  bile  salts 
were  not  markedly  affected.  When  the  mixed  urine  of 
twenty-four  hours  was  tested  no  excess  was  detected.  When 
samples  of  each  micturition  were  tested  there  was  found  to 
be  a  slight  increase  in  some,  but  this  was  not  con- 
stant. 

In  order  to  discover  what  amount  of  loss  to  the  system  was 


SIMPLE    PERSISTENT    ALBUMINURIA.  1G7 

involved  in  this  drain  of  albumen,  a  quantitative  estimation 
was  made  on  4th  Nov.  by  Esbach's  method.  It  was 
found  that  the  urine  contained  0-8  gramme  of  albumen 
per  litre,  or  0*08  per  cent.  The  total  loss  of  albumen 
in  twenty-four  hours  was  19*25  grains  —  an  amount 
really  quite  inconsiderable. 

The  characters  of  the  urine  which  I  have  described  justified 
us  in  hoping  that  this  gentleman  might,  so  far  as  his  renal 
functions  were  concerned,  expect  to  enjoy  his  active  life 
in  the  future  as  he  has  done  in  the  past.  Unfortunately 
the  glandular  disease  appears  to  be  advancing,  although 
the  renal  condition  is  at  least  no  worse.  With  no  form 
of  grave  renal  disease  could  we  have  such  a  condition  of  the 
urine.  Wherever  the  primary  fault  may  be,  it  certainly  is 
not  in  the  kidneys.  The  presence  of  an  excess  of  urea  along 
with  albumen  corresponds  with  what  Dr.  Ralfe(51)  has  found 
in  such  cases,  and  I  know  of  no  better  explanation  of  the 
condition  than  that  which  Dr.  Ralfe  has  given. 

The  features  of  this  kind  of  case  I  take  to  be  persistent 
presence  of  albumen,  usually  in  small  quantity,  with  few  tube 
casts,  and  these  mostly  hyaline,  without  diminution  of  urea, 
increased  vascular  tension,  cardiac  hypertrophy  or  other  con- 
sequence of  renal  malady,  persisting  for  a  period  of  months 
or  years,  and  little  influenced  by  diet  or  exercise.  I  cannot 
say  whether  further  experience  will  confirm  this  view  or  not. 


The  last  question  which  occurs  in  regard  to  these  cases  is 
as  to  prognosis.  Are  these  different  forms  likely  to  continue 
simple,  or  do  they  culminate  in  organic  renal  disease  ?  I 
think  that  in  the  first  category  there  is  a  slight  tendency  to 
this  latter  issue.  In  the  second  and  third  categories  it  is  less 
likely.  From  what  has  been  said  by  such  eminent  authori- 
ties as  Dr.  George  Johnson,(29)  and  Dr.  Clement  Dukes,(99)  we 


168  ALBUMINUKIA. 

cannot  but  fear  that  the  condition  does  sometimes  culminate 
in  organic  disease,  but  so  considerable  a  proportion  of  my 
cases  have  gone  on  for  long  periods  without  doing  so,  that  I 
am  confident  that  it  must  be  rare.  Dr.  George  Johnson  has 
seen  several  cases  in  which,  beginning  with  the  simple 
affection,  Bright's  disease  has  developed.  He  mentions  the 
case  of  a  distinguished  London  physician,  in  whom  at  first 
albumen  only  appeared  occasionally  after  walking  exercise, 
and  then  was  present  in  large  amount,  while  diet  had  no 
apparent  influence.  After  a  time  the  albuminuria  became 
persistent,  and  in  the  end  fatal  uraemia  resulted.  It  is,  of 
course,  possible,  that  this  was  an  example  of  cirrhotic  Bright 
from  the  first,  but  when  a  contrary  opinion  is  held  by  Dr. 
Johnson  who  saw  the  case,  we  are  bound  to  conclude  that 
the  evidence  was  strongly  in  favour  of  his  view.  Dr. 
Clement  Dukes  concludes  that  many  cases  are  without  doubt 
only  transient,  that  probably  many  persist  for  years  and  yet 
recover,  but  he  believes  that  a  large  proportion  are  simply 
the  first  stage  of  Bright's  disease. 

It  must  not  be  forgotten  that  one  may  find  in  some  cases 
of  cirrhotic  Bright's  disease  the  urine  generally  free  from 
albumen,  that  abnormality  occurring  only  when  the  patient 
has  taken  alcohol  to  excess,  has  been  chilled,  or  over-fatigued 
with  travelling.  But  in  such  cases  vascular  and  cardiac 
changes,  and  very  probably  alterations  in  the  retina  will  be 
found,  which  give  conclusive  proof  of  the  existence  of  cirr- 
hosis. Neither  must  it  be  forgotten  that  cases  of  cirrhosis 
may  show  no  albumen  in  specimens  passed  during  the  night 
or  in  the  early  morning,  while  in  the  day  and  evening  urines 
it  is  distinct  enough. 

The  fourth  category  is  one  in  which  my  prognosis  would 
be  less  hopeful.  Still,  so  long  as  the  solids  are  in  the  normal 
quantity,  and  the  vascular  changes  do  not  manifest  them- 
selves, we  may  speak  hopefully  even  in  such  cases. 


LECTURE    XII. 
ALBUMINURIA— ACCIDENTAL,  &c. 

Number  found  in  Groups  of  Patients. — From  Catamenial  and  other 
Discharges. — Discharges  from  the  Urethra. — Haemorrhages  and 
Discharges  from  Prostate. — Seminal  Fluid. — From  Bladder. — 
From  Ureters  and  Pelvis  of  Kidney. — Cases  of  Renal  Calculus. 
— Haemorrhage  from  the  Kidney. 

Albuminuria  of  Pregnancy. — Albuminuria  from  Hindered  Out/low 
dice  to  other  causes. 

Explanation  of  the  Albuminuria  in  the  Series  of  Healthy  Individuals. 
— Penal  Disease. — Accidental. — Taking  of  Food. —  Violent  or 
Prolonged  Muscular  Exertion. — Playing  upon  Wind  Instru- 
ments.— Cold  Bathing. — Mental  Conditions. 

C\  ENTLEMEN, — We  commence  to-day  by  considering  the 
group  of  accidental  albuminurias,  composed  of  cases 
in  which  albumen  is  added  to  the  urine  after  its  secretion, 
owing  to  admixture  with  blood,  pus,  prostatic  or  seminal 
fluid,  or  uterine,  or  vaginal  discharges.  Among  our  private 
patients,  eight — and  indoor  hospital  patients,  four — had 
albuminuria,  which  we  referred  to  this  category.  Among 
women  we  are  specially  liable  to  meet  with  it,  seeing  that 
vaginal  and  uterine  discharges  may  so  readily  mingle  with 
the  urine.  During  the  catamenia,  and  when  haemorrhages 
or  discharges  from  other  causes  exist,  the  urine  is  always 
contaminated,  and  the  presence  of  albumen  is  of  no  clinical 
importance.  The  microscope  reveals  in  such  cases  blood 
corpuscles,  mucus  corpuscles,  vaginal  epithelium,  and  some- 
times other  cellular  elements.      Filtration  improves  the  con- 

169 


1 70  ALBUMINURIA. 

dition  of  the  urine,  but  does  not  remove  the  albuminuria 
because  no  filter  can  retain  the  albuminous  fluid.  Dis- 
charges from  the  urethra  may  be  of  the  nature  of  pus  or 
blood.  In  men  more  especially  is  this  a  common  source  of 
contamination.  Bleeding  from  the  urethra  is  by  no  means 
usual,  but  purulent  discharges  associate  themselves  with 
every  gonorrheal  infection.  Pus  or  blood  derived  from  this 
source  is  carried  out  in  front  of  the  current  of  urine,  or  with 
its  first  portion,  but  also  comes  away,  especially  when  the 
urethra  is  pressed,  apart  from  the  act  of  micturition. 

Haemorrhages  and  discharges  from  the  prostate  are 
reckoned  by  many  as  common.  You  will  not  unfrequently 
find,  particularly  in  men  somewhat  advanced  in  life,  that 
hematuria  occurs  occasionally  in  association  with  prostatic 
enlargement.  Sometimes  it  recurs  in  an  intermittent  way 
for  years,  and  seems  practically  of  as  little  importance  as  a 
slight  bleeding  from  haemorrhoids  ;  but  it  also  sometimes 
betokens  the  development  of  malignant  disease  in  the  gland 
or  its  immediate  neighbourhood.  Discharge  of  prostatic 
fluid,  whether  connected  with  simple  prostatorrhcea  or  with 
prostatitis,  has  been  supposed  to  produce  albuminuria,  and 
Sir  Andrew  Clark (114)  has,  in  a  recent  paper,  brought  forward 
certain  observations  as  to  cases  of  acute  prostatitis  in  which 
hyaline  cylinders,  resembling  renal  tube  casts,  and  small 
flask-shaped  hyaline  masses  were  present  during  their  whole 
course.  Dr.  Campbell  Black (ll5)  of  Glasgow  had  previously 
recorded  similar  observations. 

Seminal  fluid  also,  when  mingled  with  the  urine,  produces 
a  certain  amount  of  albuminuria,  but  in  such  cases  the  albu- 
men is  seen  only  occasionally,  and  the  microscope  reveals 
spermatozoa.  I  have  known  a  patient  advanced  in  years 
much  alarmed  by  the  occurrence  of  bloody  seminal  emissions, 
the  haemorrhage  evidently  resulting  from  rupture  of  the 
fragile   vessels    in    the    prostate  or    elsewhere.     This    is    to 


RENAL    CALCULUS.  171 

be  recognised  as  an  occasional,  although  rare,  occurrence. 
Bloody,  purulent,  or  other  discharges  from  the  bladder  are 
common  causes  of  albuminuria.  The  irritation  from  vesical 
calculus,  ordinary,  acute,  or  chronic  catarrh  of  the  bladder, 
malignant  or  simple  villous  growth  from  its  mucous  mem- 
brane, are  all  familiarly  known  as  causes  of  this  condition. 
With  these  maladies  your  surgical  experience  has  made  you 
familiar.  Blood  and  pus  also  frequently  result  from  disease 
of  the  ureters  and  pelvis  of  the  kidney,  especially  from  cal- 
culus, and  the  characteristic  features  of  these  I  may  illustrate 
by  reference  to  an  acute  and  a  chronic  case.  A  patient  was 
suddenly  taken  ill  with  acute  pain  in  the  region  of  the  left 
kidney.  The  pain  varied  in  intensity  from  time  to  time,  but 
was  generally  such  as  to  make  the  patient  cry  out  and 
writhe  in  agony.  It  darted  down  not  only  towards  the 
bladder  but  along  the  front  and  inside  of  the  thigh,  and  was 
associated  with  retraction  of  the  testicle  and  nausea  with 
violent  retching.  The  urine  was  passed  frequently,  but  in 
small  quantities,  and  it  contained  a  considerable  amount  of 
blood.  Suddenly  the  acute  pain  subsided,  and  only  a  diffused 
aching  remained.  A  freer  micturition  followed,  and  as  it  was 
going  on,  a  small  calculus  was  observed  to  escape,  and  from 
that  moment  the  symptoms  of  irritation  rapidly  diminished, 
and  finally  disappeared. 

Another  patient,  a  lady  of  middle  age,  consulted  me  this 
summer  on  account  of  symptoms  which  clearly  pointed  to  the 
presence  of  a  renal  calculus.  She  had  for  a  long  time  lived 
in  India,  and  her  health  had  undoubtedly  suffered  from  the 
climate  of  that  country,  as,  in  addition  to  less  important 
tropical  maladies,  she  had  had  abscess  of  the  liver.  During 
the  last  twenty-four  years  or  so  she  had  suffered  from  severe 
attacks  of  pain  in  the  left  renal  region,  and  other  symptoms 
of  calculus,  which,  as  I  have  already  mentioned  them  in  con- 
nection with  the  previous  case,  I  need  not  recapitulate  here. 


172  ALBUMINURIA. 

For  the  first  twelve  years  or  more,  the  attacks  of  pain  were 
of  short  duration,  but  for  ten  or  twelve  years  before  I  saw 
her,  she  had  never  been  free  from  distress,  and  there  is  every 
reason  to  believe  that  during  all  these  years  the  same  calculus 
was  lodged  in  the  pelvis  of  the  kidney.  While  living  in  India, 
and  afterwards  in  England,  she  had  been  seen  by  various 
medical  men,  and  had  been  told  that  an  operation  would  be 
necessary  for  her  cure,  the  weak  state  of  her  health  alone 
preventing  that  proposal  from  being  strongly  urged.  When 
I  saw  her  this  summer  she  was  in  a  very  alarming  condition. 
The  state  of  the  urine,  which  contained  pus  in  considerable 
quantity,  with  a  small  amount  of  albumen  due  to  that,  showed 
plainly,  along  with  the  other  symptoms,  that  the  patient  was 
suffering  from  chronic  calculous  pyelitis,  and  that  probably 
there  was  a  collection  of  pus  in  connection  with  the  kidney. 
There  was  intense  pain  in  the  left  renal  region  shooting  down- 
wards and  towards  the  bladder,  and  on  palpation  there  was 
great  tenderness  in  the  left  loin,  and  a  large  and  apparently 
hard  solid  body  was  felt.  This  was  a  suspicious  element  in 
the  case,  for,  as  you  know,  in  cases  of  calculus  the  kidney 
does  not,  as  a  rule,  enlarge,  but  rather  contracts  and  atrophies 
round  the  stone.  Being  fully  satisfied  that  whatever  other 
condition  might  be  present  besides  calculus,  the  only  hope 
for  the  patient  lay  in  surgical  interference,  I  asked  Professor 
Annandale  to  see  her  in  consultation  with  me.  He  agreed 
with  my  opinion,  and  decided  to  operate  at  once.  The 
patient  having  been  anaesthetised,  a  transverse  incision  was 
made  in  the  left  loin,  and  the  large  hard  mass  could  then 
be  more  distinctly  felt.  Its  characters  were  such  that  we 
were  at  first  suspicious  that  the  long-continued  irritation  had 
set  up  malignant  disease  in  the  kidney,  as  I  have  known 
happen  in  a  similar  case  before.  Professor  Annandale,  how- 
ever, found  that  towards  the  pelvis  of  the  kidney  fluctuation 
could  be  detected,  and  on  making  an  incision  at  this  part  a 


PYELITIS.  173 

considerable  quantity  of  pus  discharged.  A  pretty  large  cal- 
culus was  then  felt  in  the  abscess  cavity,  and,  although  with 
considerable  difficulty,  it  was  successfully  removed.  It  con- 
sisted of  a  central  hard  nucleus,  of  the  size  of  a  bantam's  egg, 
covered  by  a  large  amount  of  looser  incrustation,  which  was 
mostly  broken  down  in  the  efforts  at  removing  it.  A  drainage 
tube  was  introduced,  and  the  rest  of  the  wound  was  closed 
by  sutures,  and  speedily  healed  by  first  intention.  The  pro- 
gress of  the  patient  after  the  operation  was  in  every  respect 
satisfactory.  The  pain  in  the  renal  region,  though  severe 
for  the  first  few  days,  gradually  diminished,  and  so  did  the 
hard  swelling  of  which  I  have  spoken.  Her  general  health 
steadily  improved.  In  little  more  than  a  fortnight  she  was 
able  to  be  removed  daily  to  a  couch  in  the  dining-room.  In 
three  weeks  we  thought  it  safe  for  her  to  go  out  driving 
and  within  a  month  of  the  operation  she  was  able  to  take  a 
pretty  long  railway  journey  home  without  any  untoward 
result.  The  urine,  till  shortly  before  her  departure,  contained 
a  varying  proportion  of  pus,  but  this  greatly  diminished  when 
she  was  put  upon  a  mixture  containing  potash,  hyoscyamus, 
and  uva  ursi.  Since  she  went  home  the  improvement  has 
continued;  and  now  this  patient,  after  her  twenty-four  years 
of  suffering,  may  hopefully  look  forward  to  the  enjoyment  of 
continued  good  health. 

Calculus  is  not  the  only  cause  of  pyelitis,  for  I  have  known 
an  acute  and  even  fatal  case  result  from  simple  exposure  to 
cold.  When  the  kidney  is  the  seat  of  suppurative  nephritis, 
whether  infective  or  non-infective  in  character,  albuminuria, 
and  sometimes  hsematuria,  appear ;  and  a  like  result  is  met 
with  in  strumous  disease  of  the  organ  unless  the  ureter  be 
blocked  in  such  a  way  as  to  hinder  the  downward  passage  of 
the  strumous  products. 

Hemorrhage  from  the  kidney  itself  often  produces  albu- 
minuria.    You  may  see   it   in   cases  of  renal  tumour  and 


174  ALBUMINURIA. 

infarction,  in  rupture  of  the  kidney,  in  such  diseases  as 
purpura  and  scorbutus,  and  as  a  result  of  excessive  use 
of  certain  medicines,  such  as  turpentine,  cantharides,  and 
copaiba.  It  may  also  appear  when  there  is  inflammation 
round  the  kidney,  as  in  perinephric  abscess,  probably 
usually  when  that  is  associated  with  suppurative  nephritis. 
With  hemoglobinuria,  also,  albuminuria  is  associated  under 
conditions  to  which  I  have  already  referred. 


There  remain  one  or  two  causes  of  albuminuria  which 
have  scarcely  been  brought  out  in  the  series  of  cases  which 
I  have  tabulated.  Among  them  I  shall  mention  first  the 
albuminuria  of  pregnancy.  It  may  be  variously  related  to  the 
condition.  The  pregnancy  may  coexist  with  acute  or  chronic 
organic  kidney  disease.  It  sometimes  also  arises  along  with 
other  tokens  of  obstructed  circulation  from  hindrance  to  the 
outflow  of  blood  from  the  renal  vessels.  Probably  hindrance 
to  the  outflow  of  urine  from  pressure  on  the  ureters  may  lead 
to  albuminuria  in  such  cases,  and  it  is  possible  that  altera- 
tions of  the  arterial  circulation  may  in  some  instances  bring 
about  the  like  result. 

Albuminuria  sometimes  occurs  also  in  consequence  of 
hindered  outflow  of  urine  from  the  kidney  from  causes  other 
than  pregnancy.  The  pressure  of  a  tumour,  or  obstruction 
by  a  calculus,  may  lead  to  this  result.  The  results  of 
experiments  show  that  counter-pressure  to  the  outflow  of 
urine  speedily  induces,  not  only  some  widening  out  of 
tubules,  but  changes  in  the  filtering  apparatus  which  suffice 
to  induce  albuminuria. 


We  have  thus  then  gone  over  the  causes  of  albuminuria 
in  our  series  of  patients,  and  have  endeavoured  to  explain 
how  the  symptom  arises  in  each.      It  only  remains  to  ask 


CAUSE    OF    ALBUMINURIA   IN    HEALTHY    PEOPLE.         175 

how  the  albuminuria  in  our  various  series  of  presumably 
healthy  individuals  is  to  be  explained.  Some  of  them,  no 
doubt,  were  due  to  renal  disease  in  various  forms,  some, 
probably,  to  obstructions  of  circulation  which  did  not  inter- 
fere with  the  general  health,  and  some  may  have  been  due 
to  accidental  causes,  notwithstanding  the  precautions  which 
we  took  to  avoid  this  source  of  fallacy.  But  these  do  not 
account  for  all  the  cases,  and  it  remains  for  us  to  inquire 
particularly  why  the  taking  of  food  and  the  violent  or  pro- 
longed muscular  exertion  induced  albuminuria  in  so  many. 

I  do  not  believe  that  such  albuminurias  can  be  correctly 
referred  to  mere  increase  of  mucin,  although  that  does 
occur  after  the  ingestion  of  food.  It  is  a  true  albuminuria, 
and  looking  at  our  four  sets  of  causes  we  recognise,  as 
a  possible  explanation,  changes  in  the  blood,  either  in 
respect  of  salts  or  its  albuminous  elements  ;  but  this  is  not 
proved  to  be  an  important  cause,  and  sometimes  the  symptom 
comes  on  so  suddenly  as  to  make  this  explanation  extremely 
improbable.  As  to  changes  in  the  filtering  apparatus,  it 
does  not  seem  probable  that  this  affords  an  explanation. 

If  we  were  more  certain  as  to  the  effects  of  modification 
of  the  blood  pressure  we  might  find  in  changes  produced 
through  the  action  of  the  nervous  system  a  somewhat 
attractive  hypothesis.  Certainly  it  is  in  some  cases  more 
like  the  result  of  a  nerve  influence  than  anything  else.  We 
have  no  right  whatever,  in  the  present  state  of  our  know- 
ledge, to  assume  a  morbid  action  on  the  part  of  the  renal 
epithelium. 

The  albuminuria  following  upon  severe  muscular  exertion, 
on  the  other  hand,  may  result  from  either  of  two  causes. 
There  may  be  such  alteration  of  the  blood  pressure 
throughout  the  system  generally,  or  in  the  kidneys,  as 
determines  the  condition ;  or  the  introduction  into  the 
circulation  of  an  abnormal  amount  of  albuminous  or  saline 


176  ALBUMINURIA. 

waste  products  may  induce  it  in  individuals  predisposed  to 
albuminuria. 

It  may  also  be  asked  how  it  happens  that  moderate 
exercise  brings  certain  dietetic  albuminurias  to  an  end. 
This  may  depend  upon  chemical  influences,  using  up  materials 
which  were  being  poured  out  from  the  blood,  or  more  likely 
upon  vascular  influence,  a  general  toning  up  of  the  circulation 
relieving  a  local  overfilling,  a  result  of  some  weakness  of  the 
kidney. 

The  influence  of  playing  upon  wind  instruments,  of  cold 
bathing,  and  of  mental  conditions,  may  be  explained  in  the 
rare  cases  in  which  they  do  occur,  the  first  by  a  reference  to 
altered  states  of  the  circulation  resulting  from  the  effort  of 
playing,  the  second  by  nerve  influence  exerted  upon  the 
vessels  of  the  kidney,  and  partly  by  interference  with  the 
action  of  the  skin,  and  the  third  by  influence  propagated 
through  the  nerves  to  the  renal  vessels. 


LECTUKE    XIII. 

ON  THE  DIFFERENTIAL  DIAGNOSIS  AND  THE 
PROGNOSIS  IN  ALBUMINURIA. 

Diagnosis. — Is  the  Albuminuria  Constant,  Intermittent,  or  Cyclic? — 
Quantity  of  Albumen  discharged. —  Variety  of  Albumen  present. 
— Quantity  of  Urine  passed  daily. — Specific  Gravity.  —  Tube 
Casts. — Other  Urinary  Conditions,  Phosphaturia,  Oxaluria, 
Urates. — General  Considerations. — Alimentary  System. — Haimo- 
poietic  System. — Circulatory  System. — Respiratory  System. — 
Integumentary  System. — Nervous  System. — Locomotory  System. 

Prognosis. — Importance  of  the  Drain  of  Albumen. — Data  for  estimat- 
ing daily  loss,  and,  its  proportion  to  amount  of  Albumen  in  the 
Blood. — Prognosis  in  Inflammatory  Bright' s  Disease. — Cirrhosis 
of  the  Kidneys. —  Waxy  Kidney — In  Febrile  Albuminuria. — 
In  Albuminuria  from  Alimentary  Diseases. — From  Nervous 
Derangements. — From  Glycosuria. — In  Paroxysmal,  Dietetic, 
Exercise,  and  Simple  Persistent  Albuminuria. — In  Accidental 
Albuminuria. — In  Albuminuria  from  Blood  Diseases. 

C\  ENTLEMEN, — You  will  find  in  practice  that  questions  of 
diagnosis  as  to  the  cause  of  albuminuria  frequently 
arise,  and  that  not  unfrequently  it  is  very  difficult  to  satisfy 
yourselves  on  the  point.  You  will  find  also  that  the  question 
of  prognosis  involves  both  difficulty  and  responsibility.  I 
intend  to  devote  this  lecture  to  a  survey  of  the  considerations 
which  guide  the  physician  in  determining  such  questions. 

Starting  from  the  general  fact  of  albuminuria,  the  first 
question  that  we  have  to  solve  is  whether  it  is  constant, 
affecting  the  urine  of  every  micturition,  intermittent,  appear- 
ing only  now  and  then,  or  cyclic,  occurring  regularly  at  cer- 

177  N 


178  ALBUMINURIA. 

tain  periods  and  not  at  others.  If  it  be  found  to  be  cyclic, 
completely  absent  at  one  part  of  the  twenty-four  hours  and 
present  at  others,  the  diagnosis  of  functional  albuminuria  is 
rendered  probable,  and  this  with  the  greater  confidence  the 
more  regular  the  cyclic  character  is  found  to  be  on  different 
days.  But  the  mere  absence  of  albumen  from  the  urine 
passed  on  rising  in  the  morning  is  not  incompatible  with  the 
existence  of  most  serious  organic  disease,  for  in  cirrhosis  this 
condition  is  sometimes  seen.  If  a  cycle  of  a  different  kind 
manifest  itself, — if,  for  example,  a  patient  gets  albuminuria 
only  during  the  warm  part  of  summer,  or  during  the  cold  of 
winter,  whether  it  then  presents  a  daily  cycle  of  changes  or 
not,  the  probability  is  that  it  will  prove  simply  functional. 
But  even  with  this  you  must  remember  that  in  some  cases  of 
cirrhosis,  and  perhaps  in  some  of  very  slight  tubular  inflam- 
mation, albumen  may  appear  during  cold  weather,  and  be 
ordinarily  absent. 

If  the  albuminuria  be  intermittent,  that  is,  be  occasionally 
present  and  occasionally  absent  without  manifesting  any 
distinct  regularity,  a  certain  degree  of  probability  attaches  to 
diagnosis  of  functional  disease,  and  this  especially  if  the 
albuminuria  be  found  to  stand  related  to  special  circum- 
stances, in  particular  to  the  ingestion  of  food,  the  change  of 
attitude  of  the  patient  from  the  recumbent  to  the  erect  posi- 
tion or  to  muscular  exercise.  Still  it  must  be  kept  in  view 
that  albumen  may  appear  and  disappear  under  other  condi- 
tions, that  in  the  earlier  stages  of  cirrhosis,  and  perhaps  also 
of  waxy  disease  of  kidney,  it  may  be  present  at  one  time  and 
absent  at  another  in  the  same  day,  or  it  may  make  its 
appearance  for  a  time,  say  for  a  week  or  two,  and  then 
disappear  altogether  for  a  considerable  period.  I  have 
known  a  patient,  for  example,  showing  symptoms  of  renal 
cirrhosis  whose  urine  was  ordinarily  quite  free  from  albu- 
men, but  who  developed  the  condition    under  the  fatigue 


DIAGNOSTIC    INDICATIONS.  179 

and  excitement    of   a    railway  journey,   and    a    visit    to    a 
physician. 

If  the  albuminuria  be  constant,  even  although  it  may  vary 
somewhat  in  amount  at  different  times,  there  is  a  greater 
probability  of  organic  changes  in  the  kidney,  but  this  con- 
sideration is  far  from  being  of  itself  pathognomonic,  for,  as  we 
have  seen,  there  are  cases  of  simple  persistent  albuminuria, 
truly  functional  in  their  character,  which  may  go  on  for  long 
periods,  and  terminate  in  complete  recovery. 

When  in  any  case  you  find  that  the  albuminuria  comes  on 
distinctly  and  only  after  meals,  on  change  of  attitude, 
after  more  or  less  severe  muscular  exertion,  under  mental 
excitement,  or  after  cold  bathing,  you  may  conclude  with 
certainty  that  the  process  is  functional. 

The  quantity  of  albumen  discharged  is  of  no  great 
diagnostic  importance.  In  many  purely  functional  cases  it 
is  large.  In  some  hopeless  organic  cases  it  is  small.  It  is,  as 
a  rule,  most  abundant  in  inflammatory  Bright's  disease,  and 
in  the  combined  forms.  It  is  small  in  the  early  stages  of 
cirrhosis  and  of  waxy  degeneration,  is  almost  always  scanty 
in  the  cases  associated  with  nerve  lesion  and  usually  in  those 
of  circulatory  origin.  In  many  of  the  dietetic  and  other 
functional  varieties  it  is  also  small,  but  I  have  seen  it  in  some 
of  these  as  copious  as  in  inflammation. 

The  variety  of  albumen  present  has  not  yet  been  proved  to 
possess  diagnostic  importance.  It  may  turn  out  that  the 
presence  of  a  larger  proportion  of  globulin,  or  the  exclusive 
presence  of  peptones,  may  enable  us  to  make  out  certain 
points,  but  my  observations  do  not  bear  out  the  suggestion 
of  Senator (20)  on  the  one  hand,  that  globulin  is  specially 
characteristic  of  waxy  disease,  or  of  Maguire,(54)  on  the  other, 
that  it  stands  so  related  to  functional  albuminuria.  With 
regard  to  peptones,  we  find  them  in  cases  of  renal  inflamma- 
tion,   chronic    suppuration,    and    waxy    disease,    sometimes 


180  .  ALBUMINURIA. 

in  fevers,  and  in  pneumonia  about  the  stage  of  resolution,  but 
we  are  not  entitled  at  present  to  attach  diagnostic  importance 
to  them. 

The  quantity  of  urine  sometimes  affords  important  diag- 
nostic indications.  If,  apart  from  the  effect  of  the  atmosphere 
and  the  diet,  the  quantity  be  excessive,  the  case  generally 
turns  out  to  be  either  waxy  disease  or  cirrhosis.  The  poly- 
uria appears  in  waxy  cases  at  an  early  stage,  sometimes  even 
before  the  albumen.  It  is  always  at  a  later  stage  in 
cirrhosis.  I  have  observed  in  a  number  of  cases,  where  the 
bladder  has  become  distended  from  prostatic  disease,  that  not 
only  are  there  frequent  calls,  but  that  the  total  amount  of 
urine  is  increased.  Such  patients  pass  large  quantities  of 
pale,  often  slightly  opaque,  and  albuminous  urine.  The 
opacity  is  sometimes  due  to  the  admixture  of  catarrhal  pro- 
ducts, sometimes  to  bacteria,  or  to  a  combination  of  the  two. 
If  the  amount  be  exceptionally  small,  we  may  suspect  obstruc- 
tion in  some  part  of  the  urinary  tract,  either  in  the  uriniferous 
tubules,  in  consequence  of  inflammatory  blocking,  or  lower 
down,  as  from  occlusion  of  the  ureters.  The  quantity  is  also 
diminished  in  cases  due  to  increased  backward  pressure  on  the 
renal  vessels,  and  is  sometimes  scanty  when  there  is  catarrh 
of  the  bladder  or  pyelitis. 

The  specific  gravity  and  amount  of  urea  are  often  very 
important  aids  to  diagnosis.  If  the  specific  gravity  is  high, 
we  commonly  find  either  that  the  albuminuria  is  functional 
or  is  associated  with  fever,  cardiac  disease,  or  glycosuria,  or 
with  a  comparatively  early  stage  of  acute  inflammation  of 
the  kidneys.  In  the  other  conditions  it  is,  as  a  rule,  sub- 
normal. But  the  amount  of  urea  discharged  daily  is  far  more 
important.  In  a  considerable  proportion  of  the  functional 
cases  it  is  at  least  up  to  or  even  above  the  normal  standard. 
In  waxy  disease  of  the  kidneys  it  is  up  to  that  standard  at 
the    beginning,    but    gradually    diminishes    as    the    disease 


DIAGNOSTIC    INDICATIONS.  181 

advances.  In  cirrhosis  of  the  kidney  it  is  diminished 
throughout,  and  in  tubular  inflammation  it  is  generally  below 
the  normal  standard.  In  cardiac  cases  it  is  diminished.  In 
fevers  the  urea  is  very  frequently  increased  above  the  habitual 
standard  of  the  patient.  Even  in  fever  occurring  in  the 
course  of  renal  cirrhosis  I  have  seen  it  rise  to  the  normal 
standard.      With  glycosuria  there  is  often  also  an  increase. 

With  regard  to  tube  casts,  it  must,  I  think,  be  admitted 
that  their  diagnostic  importance  was  overestimated  when 
their  existence  was  first  recognised.  Almost  any  condition 
which  may  give  rise  to  albuminuria  may  also  produce  casts. 
Still,  much  may  be  learned  from  a  study  of  their  character- 
istics. Epithelial  and  fatty  casts  afford  definite  evidence 
of  the  existence  of  inflammation  of  the  tubules.  Hyaline 
casts,  associated  with  them,  or  containing  here  and  there 
fatty  granules,  results  of  disintegration  of  epithelial  cells,  also 
give  evidence  of  a  more  advanced  stage  of  the  process.  Casts 
containing  blood-corpuscles  or  pus  give  definite  evidence  of  the 
presence  of  haemorrhage  or  of  suppuration  in  the  renal  tissues, 
but  the  mere  presence  of  simple  hyaline  casts  may  be  associ- 
ated with  waxy  disease  or  with  cirrhosis  of  kidney,  with 
simple  persistent,  with  cardiac,  alimentary,  or  other  varieties 
of  albuminuria.  Sir  Andrew  Clark,(m)  Dr.  Campbell  Black,(115) 
and  other  reliable  observers,  have  recorded  the  fact  that  they 
have  met  with  bodies  resembling  renal  casts,  which  were  really 
casts  from  the  prostate.  Cases  of  jaundice  and  of  oxaluria 
frequently  exhibit  true  renal  casts,  the  delicate  hyaline  out- 
line being  rendered  the  more  distinct  in  the  one  case  by  the 
tinging  and  the  granular  urates,  and  in  the  other  by  the 
octahedral  crystals  scattered  throughout  them. 

Other  urinary  conditions  which  sometimes  possess  a  degree 
of  diagnostic  value  are  the  occurrence  of  phosphates,  oxalates, 
or  urates  along  with  the  albumen.  When  we  find  that  a 
urine  which  is  sometimes  albuminous  also  shows  at  times  a 


182  ALBUMINURIA. 

sudden  copious  deposit  of  phosphates,  we  Toaa,y  conclude  that 
the  albuminuria  is  functional,  and,  though  with  less  certainty, 
a  sudden  and  abundant  deposit  of  oxalates  may  give  a  like 
indication.  Urates  occur  so  often  in  association  with 
albuminuria,  in  acute  nephritis,  in  febrile  and  inflammatory 
conditions,  and  in  cardiac  cases,  as  well  as  in  some  simply 
functional  ones,  that  their  indications  are  unimportant. 

Apart  from  the  characters  of  the  urine,  there  are  certain 
general  conditions  which  must  be  considered  in  relation  to 
diagnosis.  Sex  is  practically  of  no  importance.  Age  is  also 
of  comparatively  little  service ;  only  one  should  remember 
that  about  the  time  of  puberty  functional  albuminuria  is 
most  apt  to  set  in.  Occupation  and  habits,  also,  possess  no 
special  value  in  diagnosis.  The  general  appearance  of  the 
patient  often  affords  important  information.  The  existence 
of  marked  dropsy  implies  either  inflammatory  disease  of  the 
kidneys  or  cardiac  disease,  or  great  deterioration  of  blood. 
There  is  a  peculiar  appearance  of  the  face,  somewhat  difficult 
to  describe,  which  is  characteristic  of  many  of  the  functional 
cases.  It  is  marked  by  pallor,  with  slight  oedema  of  eyelids, 
and  a  certain  laxity  of  tissue,  with  a  general  languor  of  circu- 
lation and  unfitness  for  exertion.  But  a  similar  appearance 
often  coexists  with  waxy  disease,  and,  of  course,  is  common 
enough  apart  from  albuminuria.  The  general  appearance 
characteristic  of  patients  suffering  from  cardiac  and  diabetic 
albuminuria  need  not  be  referred  to. 

The  condition  of  systems  other  than  the  urinary  often 
throws  great  light  on  the  question  of  diagnosis.  The  alimen- 
tary system  may  give  you  important  hints,  especially  in  the 
case  of  waxy  disease  when  there  is  evidence  of  enlargement 
of  the  liver,  or  intractable  dyspepsia  indicating  degeneration 
of  the  vessels  of  the  gastric  mucous  membrane,  or  diarrhoea 
indicating  the  more  common  implication  of  the  intestine. 
Other  abnormalities,  although  often  of  clinical  importance, 


DIAGNOSTIC    INDICATIONS.  183 

are  of  little  service  in  diagnosis.  Obviously  cases  in  which 
the  ingestion  of  food  or  the  process  of  digestion  induces  or 
greatly  increases  the  albuminuria  are  most  likely  to  be 
referred  to  the  functional  group. 

From  the  state  of  the  hsemopoietic  system  there  is  little 
to  be  gained  in  the  way  of  diagnosis.  The  enlargement  of 
the  spleen,  however,  if  associated  with  other  recognised  com- 
plications, may  give  an  indication  of  waxy  disease,  and  a 
tendency  of  the  red  blood  corpuscles  to  adhere  to  one  another 
and  to  tail  may  also  suggest  the  presence  of  this  form  of 
degeneration. 

The  circulatory  system,  on  the  other  hand,  affords  very 
important  indications.  The  tension  of  the  pulse,  the  changes 
in  the  heart  and  in  the  blood-vessels,  take  the  first  place. 
Increased  pulse  tension  is  very  characteristic  of  cirrhosis  of 
the  kidney,  and  of  inflammation  of  the  tubules  in  its  fully 
developed  and  advanced  stages.  It  is  true  that  in  some 
cases  of  post-scarlatinal  albuminuria  an  increase  of  blood 
pressure  is  found  to  precede  the  appearance  of  albuminuria  ; 
but  albuminuria  does  not  constantly  follow  upon  this  condi- 
tion, and  the  increased  pressure  is  not  proved,  as  in  the  later 
stages,  to  be  definitely  related  to  changes  in  the  renal 
circulation.  It  is  not  met  with  in  waxy  disease  unless  the 
malady  be  far  advanced,  and  probably  associated  with 
cirrhosis.  It  is  very  rare  in  the  alimentary,  circulatory, 
nervous,  and  functional  cases  ;  and  though  it  is  often  seen  in 
fever  cases  which  are  attended  by  albuminuria,  it  is  not,  as 
a  rule,  when  these  have  the  highest  tension  that  the  albu- 
minuria appears.  In  many  of  the  circulatory,  febrile,  and 
functional  cases  the  tension  is  markedly  subnormal. 

The  auscultatory  changes  in  the  heart,  in  particular  the 
accentuation  of  the  second  sound  in  the  aortic  area,  and  the 
prolonged  or  booming  character  of  the  first,  correspond  pre- 
cisely in  their  indications  with  the  increased  tension.     The 


184  ALBUMINURIA. 

same  may  be  said  to  be  true  of  the  hypertrophy  of  the  left 
ventricle  when  it  manifests  itself  in  other  ways  than  the 
altered  first  sound  already  referred  to.  Thickening  of  vessels 
is  more  common  in  renal  cirrhosis,  and  in  advanced  inflam- 
mation, and  in  cases  due  to  heart  disease,  than  in  those  con- 
nected with  any  of  the  other  causes.  But  the  diagnostic 
indications  to  be  derived  from  it  are  not  very  important. 
The  respiratory  changes  may  be  of  moment  as  indicating 
phthisis  or  other  chronic  or  debilitating  process,  which  might 
cause  waxy  disease,  otherwise  they  afford  little  diagnostic 
indication. 

The  integumentary  system,  by  the  presence  of  anasarca, 
often  gives  indication  of  the  existence  of  organic  renal  or 
cardiac  disease,  while  syphilitic  eruptions,  or  the  cicatrices 
resulting  from  them,  may  point  to  possible  waxy  disease, 
and  subcutaneous  hemorrhages  may  be  the  token  of  blood 
diseases,  such  as  purpura,  scorbutus,  and  pernicious  anaemia. 
Changes  such  as  those  characteristic  of  Raynaud's  disease 
may,  on  the  other  hand,  indicate  other  blood  diseases  or 
nervous  maladies.  An  abnormal  dryness,  and  sometimes  a 
reddish-brown  discoloration  of  the  skin,  may  attend  upon 
renal  cirrhosis,  and  simple  dryness  upon  albuminuria  with 
glycosuria. 

Among  the  symptoms  referable  to  the  nervous  system 
there  are  many  which  afford  suggestions  for  diagnosis. 
Dimness  of  vision,  whether  uraemic  or  connected  with  changes 
of  the  retina  revealed  by  the  ophthalmoscope,  gives  distinct 
indication  of  organic  renal  disease,  and  that  usually  in 
advanced  cirrhosis,  inflammatory,  or  complicated  waxy  cases. 
Uraemic  seizures  of  whatever  kind,  indicate  formidable 
organic  renal  disease.  Headaches  are  often  results  of 
organic  renal  processes,  but  they  also  occur  with  functional 
albuminuria.  Complications  of  the  nature  of  paralysis  often 
afford    a    similar    indication,    but    as    they    are    sometimes 


PROGNOSIS.  ISO 

associated   with    syphilis    they   may    indicate  rather,  under 
certain  conditions,  a  tendency  to  waxy  disease. 

The  locomotory  system  affords  little  aid  to  diagnosis 
excepting  where  there  is  caries  or  necrosis  tending  to  induce 
the  waxy  degeneration. 


We  have  now  to  consider  what  is  the  prognosis  in  the 
different  groups  of  cases,  and  I  shall  take  them  up  in  the 
same  order  as  in  previous  lectures. 

A  preliminary  question  however  arises  as  to  the  importance 
of  the  drain  of  albumen  from  the  system.  The  largest  amount 
discharged  by  a  patient  in  my  wards  during  last  winter  session 
was  between  400  and  500  grains  in  the  twenty-four  hours, 
but  in  most  cases  the  quantity  was  very  much  less.  Now 
400  grams  of  albumen  is,  of  course,  a  large  amount,  and 
when  we  compare  it  with  the  amount  of  albuminous  food 
taken  in  the  course  of  twenty-four  hours,  or  with  the 
amount  of  albuminous  material  in  the  blood  it  is  seen  to 
involve  a  very  formidable  daily  loss.  The  albuminous  material 
in  an  ordinary  diet  table  for  twenty-four  hours  is  about 
4*25  ounces,  or  2040  grains,  so  that  a  loss  of  one-fourth  part 
of  the  amount  taken  occurred  in  that  particular  patient. 
But  we  have  to  consider  that  probably  considerably  less  than 
the  whole  amount  of  what  is  taken  is  actually  assimilated 
and  converted  into  blood  albumen.  As  to  the  total  amount 
of  albuminous  materials  in  the  blood,  they  are  reckoned, 
apart  from  the  haemoglobin,  as  amounting  to  7  per  cent. 
Now,  the  total  amount  of  the  blood  being  held  to  be  one- 
thirteenth  of  the  weight  of  the  body,  we  should  calculate  that 
a  person  weighing  10  stones  would  have  about  10 "7  lbs.  of 
blood,  which  would  contain  about  12  ounces  of  albumen. 
Now  my  patient  was  losing  one  ounce  of  this  material  in 
twenty-four  hours,  that  is  to  say,  one-twelfth  part  of  the 
elaborated    albumen    of   the    blood.      Such    a     drain    must 


186 


ALBUMINURIA. 


have    involved    a    heavy   tax    upon    the   power    of    blood 
formation. 

To  give  our  ideas  of  the  loss  of  albumen  more  definite- 
ness,  I  have  prepared  a  formula  by  which,  using  Esbach's 
method,  we  can  easily  calculate  in  any  case  what  proportion 
of  the  total  amount  of  albumen  of  the  blood  is  being  daily 
lost. 


Albumen  in  grammes               Pp,.fw 
per  litre.                        ^el  Lent- 

Grains  of  Albumen  per 
Ounce  of  Urine. 

Albumen  in  Blood  per 
Stone  of  Body  Weight. 

0-5                               0-05 

0-21875 

5277  grains. 

In  the  first  column  of  the  table  is  placed  the  smallest 
amount  of  albumen  in  grammes  per  litre,  which  Esbach's 
tubes  indicate,  in  the  next,  the  per  cent,  of  albumen  to  which 
this  corresponds,  and  in  the  third  the  weight  in  grains  of  the 
corresponding  amount  of  albumen  which  would  be  contained 
in  an  ounce  of  the  urine.  In  the  fourth  column  is  given  an 
estimation  from  the  most  reliable  data  of  the  weight  of  blood 
albumen  per  stone  of  body  weight  of  the  individual.  The 
total  weight  of  albumen  lost  in  twenty-four  hours  is  obtained 
by  multiplying  the  weight  in  the  third  column  by  the  number 
of  ounces  of  urine  passed,  and  by  the  multiple  of  0*5 
grammes  which  the  estimation  of  the  albumen  by  Esbach's 
method  gives.  The  total  blood  albumen  in  the  body  is  easily 
obtained  from  the  albumen  per  stone  by  simple  multiplica- 
tion or  rule  of  three.  By  dividing  this  by  the  weight  of 
albumen  in  the  twenty-four  hours'  urine,  we  get  the  propor- 
tion of  the  total  albumen  of  the  blood  which  is  lost  daily. 
Thus,  for  example,  in  a  patient  suffering  from  a  combination 
of  the  different  varieties  of  Bright' s  disease,  the  urine  con- 
tained 2  0  grammes  per  litre.  His  body  weight  was  about  1 0 
stones.  The  quantity  of  urine  was  50  ounces,  so  that  the 
weight  of  albumen  lost  in  twenty-four  hours  was  0*21875  x 


PROGNOSIS.  187 

50  x  40  =  437'5  grains.  The  patient's  weight  being  10  stones, 
the  total  albumen  of  his  blood  would  weigh  5277  grains. 
Now,  by  dividing  this  by  the  amount  lost  daily,  we  find  that 
the  daily  drain  amounted  to  nearly  one-twelfth  of  the  total 
albumen  in  the  blood.  The  calculation  may  be  expressed 
thus  : — 

0-21875x50x40  1 


5277x10  1206 


This,  of  course,  is  an  extreme  case.  The  vast  majority  of 
albuminurics  lose  nothing  like  this  quantity.  In  one,  indeed, 
of  my  functional  cases,  which  we  worked  out  with  the  view 
of  determining  the  daily  loss,  this  was  found  to  amount  to 
only  between  5  and  6  grains  in  the  twenty-four  hours, 
although  the  reaction  was  at  certain  times  of  the  day  very 
distinct. 

In  regard  to  Bright's  disease,  the  prognosis  varies  greatly 
according  to  the  form  or  forms  present.  In  uncomplicated 
acute  inflammatory  Bright's  disease,  whether  infective  or  not, 
the  prognosis  is,  as  a  rule,  favourable.  By  proper  treatment 
a  complete  recovery  may  be  obtained  in  a  large  proportion  of 
cases,  and  this  even  after  the  patient  has  passed  into  a  state  of 
acute  uraemia  with  general  convulsions,  coma,  and  complete,  or 
almost  complete,  suppression  of  urine.  Some  cases,  however, 
especially  those  of  the  glomerular  variety,  prove  very  rapidly 
fatal  by  uraemia  or  by  some  of  the  other  complications,  such 
as  pericarditis,  oedema  of  the  brain,  &c.  Other  cases  do  not 
recover,  but  pass  into  the  chronic  form  of  nephritis.  One 
further  remark  I  have  to  add  is  that  the  prognosis  of  acute 
nephritis  in  pregnancy  is,  as  a  rule,  favourable.  Even  after 
eclampsia  and  organic  eye  changes  have  become  developed, 
complete  recovery  may  be  obtained.  Still  in  some  of  these 
also  the  disease  passes  into  the  chronic  stage.  In  some 
cases  of  albuminuria  in  pregnancy,  however,  the  nephritis  is 


188  ALBUMINURIA. 

more  chronic  from  the  outset,  and  in  these,  of  course,  the 
prognosis  for  complete  recovery  is  less  hopeful.  In  regard 
to  chronic  nephritis  in  other  conditions,  while  in  some  cases 
complete  recovery  may  be  obtained,  as  a  rule,  the  case 
pursues  a  slow  course,  with  gradually  increasing  impairment 
of  the  general  health,  and  with  the  development  of  complica- 
tions which  I  have  described,  some  of  which,  such  as  the 
cardiac  and  cerebral,  may  at  any  time  prove  rapidly  fatal. 
The  course  is  not  usually  very  prolonged,  but  it  may  be  so, 
authentic  cases  being  on  record  in  which  a  period  of  thirty 
years  has  elapsed  from  the  onset  of  the  acute  inflammatory 
attack  till  the  fatal  issue  of  the  chronic  disease  super- 
vened. 

In  regard  to  cirrhosis  of  the  kidney,  the  prognosis  is, 
I  need  scarcely  say,  hopeless,  so  far  as  complete  recovery  is 
concerned.  The  course  may  be  comparatively  rapid  in 
some  cases  —  a  tendency  to  acute  inflammation  being 
frequently  present  —  while  in  others  it  is  very  chronic  — 
the  patient  living  for  many  years  after  the  detection  of  the 
disease.  Careful  treatment  and  guidance  as  to  climate,  mode 
of  life,  food,  and  medicine,  and  attention  to  the  complications 
apt  to  arise  in  special  cases,  may  in  this  form,  and  in  the 
chronic  inflammatory  also,  greatly  prolong  the  life  of  the 
patient,  and  diminish  his  discomfort.  Still  we  can  do 
nothing  to  arrest  the  progress  of  the  malady.  As  to  the 
prognosis  of  the  probable  duration  of  any  individual  case, 
we  must  be  guided  mainly  by  the  condition  of  those  organs 
affections  of  which  are  known  to  lead  to  a  fatal  issue.  The 
state  of  the  cardiac  muscle,  not  so  much  as  regards  hyper- 
trophy, but  rather  as  to  the  presence  or  absence  of  degenera- 
tion and  failure  of  its  power,  is  important.  The  importance 
of  cerebral  and  eye  symptoms  also  I  need  not  further  impress 
upon  you.  I  would  only  remark  in  addition  that,  cirrhosis 
being  often  complicated  by  the  superaddition  of  inflamma- 


PROGNOSIS.  189 

tion  of  the  tubules,  we  can  often,  by  the  cure  of  the  latter, 
tide  the  patient  over  periods  of  urgent  danger. 

In  waxy  disease  the  prognosis  must  be  regarded  as  grave, 
especially  as  we  seldom  have  it  in  our  power  to  remove  the 
cause  of  degeneration.  Still,  when  this  can  be  achieved  we 
need  not  lose  hope,  for  I  have  seen  a  patient  with  well 
developed  waxy  degeneration  brought  to  a  fair  state  of 
health,  the  waxy  material  being  evidently  replaced  by 
more  healthy  tissue.  The  treatment  of  the  cause,  with  the 
improvement  of  the  general  tone  and  the  avoidance  or  cure 
of  complications,  constitute  our  best  means  of  prolonging 
the  life  of  the  patient. 

In  the  other  diseases  in  which  albuminuria  is  met  with  as 
a  complication,  the  prognosis  depends  as  a  rule  very  little  on 
that  symptom.  The  presence  of  a  well  marked  albuminuria 
in  fevers  increases  the  gravity  of  the  case.  But  when  it  is 
associated  with  a  strong,  bounding  pulse  and  vigorous  cardiac 
action,  it  is  much  less  grave  than  when  the  pulse  becomes 
feeble  and  perhaps  irregular,  and  the  heart's  action  flags. 
It  is  most  grave  of  all  in  cases  where  there  is  a  septic  process 
going  on,  as  in  pyaemia  and  in  fevers  with  typhoid  or  putrid 
symptoms. 

Albuminuria  in  circulatory  diseases  indicates  marked 
failure  of  circulation,  and  backward  pressure  in  the  veins. 
This  may  be  overcome  by  rest,  cardiac  and  other  tonics, 
diuretics,  and  means  of  removing  oedema  and  collections  of 
fluid  in  serous  cavities.  If  these  remedies  fail,  the  prog- 
nosis is  very  grave,  but  the  albuminuria  is  not  the  cause  of 
danger. 

Albuminuria  is  associated  with  such  varying  conditions  of 
the  alimentary  system  that  the  most  that  can  be  said  is  that 
the  prognosis  depends  on  the  nature  of  the  disease  present. 
Where  that  is  simply  a  functional  derangement,  of  some 
part  or  other  of  the  digestive  system,  as  in  dietetic  albumin- 


190  ALBUMINURIA. 

uria,  suitable  treatment  may  remove  the  condition.  Where 
the  disease  is  organic,  though  appropriate  treatment  may  do 
good  to  the  patient,  and  lessen  or  even  remove  the  albumin- 
uria, the  ultimate  prognosis  is  bad. 

Almost  the  same  remarks  apply  to  albuminuria  from 
nervous  derangements.  In  functional  diseases,  such  as 
exophthalmic  goitre,  as  I  have  pointed  out,  the  disease  may 
be  cured  and  the  albuminuria  disappear  with  it. 

Albuminuria  is  a  very  serious  complication  of  glycosuria, 
but  its  gravity  in  each  case  must  depend  on  the  condition  of 
the  kidney  producing  it,  and  on  the  state  of  the  patient  in 
other  respects.  If  the  glycosuria  is  only  temporary,  the 
albuminuria  may  pass  off  with  it ;  and  I  may  remind  you 
that  the  two  symptoms  are  sometimes  associated  in  cases  of 
functional  albuminuria,  in  which,  as  you  are  aware,  the  prog- 
nosis is  good. 

In  paroxj^smal  and  dietetic  albuminuria,  in  albuminuria 
from  exercise  or  muscular  exertion,  and  in  simple  persistent 
albuminuria,  the  prognosis  is  good,  less  so,  perhaps,  in  the 
last  than  in  the  other  three.  In  that  variety  the  difficulty 
is  greatest  of  differentiating  it  with  certainty  from  forms  of 
albuminuria  due  to  more  grave  conditions.  The  points  to 
which  I  have  referred  in  speaking  of  these  forms  of  albumin- 
uria must  be  borne  in  mind  in  making  the  differential  diag- 
nosis. If  such  cases  do  not  yield  to  treatment,  but  persist 
for  long  periods,  there  must  be  a  fear  lest,  though  only 
functional  at  the  first,  and  even  though  the  albumen  only 
appears  at  certain  periods  of  the  day,  ultimately  the  continu- 
ance of  this  abnormality  may,  through  impaired  health  and 
renal  irritation,  lead  to  the  development  of  organic  disease 
of  the  kidneys.  My  own  observations  lead  me  to  think  that 
this  is  not  a  very  frequent  termination,  still  it  is  one  to 
which  we  must  not  shut  our  eyes.  A  careful  watch  must 
be  kept   in  such   prolonged  cases  to  see  that  none  of  the 


PROGNOSIS.  191 

complications  indicating  organic  disease  are  manifesting 
themselves,  for  then  the  prognosis  would  be  entirely  changed. 
A  fuller  discussion  of  this  subject  will  be  found  in  the 
lecture  devoted  to  these  forms  of  albuminuria. 

In  regard  to  albuminuria  due  to  accidental  causes,  the 
prognosis  must  depend  on  the  prospect  of  curing  the  disease 
on  which  it  depends.  I  must  remind  you  that  even  the 
most  simple  case  of  albuminuria  due  to  irritation  of  the 
urinary  passages  is  not  without  serious  danger,  for  the  irrita- 
tation  may  spread  upwards  from  the  urethra  to  the  bladder, 
from  the  bladder  to  the  ureters  and  pelvis  of  the  kidney,  and 
from  thence  to  the  kidney  itself ;  or  an  attack  of  nephritis 
and  even  suppression  of  urine  may  result  from  reflex  irrita- 
tion from  some  inflamed  area  of  the  urinary  tract.  Especially 
if  the  process  has  become  septic  is  this  danger  present. 
Thus,  in  some  of  the  diseases  of  the  bladder,  such  as  enlarged 
prostate,  stone,  &c,  septic  mischief  may  extend  to  the 
kidney  and  lead  to  the  development  of  what  is  called 
"surgical  kidney,"  with  the  characters  of  which  you  have 
doubtless  become  acquainted  in  the  post-mortem  room.  In 
diseases  with  obstruction  to  the  outflow  of  urine,  such  as 
stone  or  enlarged  prostate,  renal  changes,  somewhat  of  the 
nature  of  cirrhosis,  are  not  infrequently  developed,  and 
I  need  not  impress  upon  you  the  influence  which  such  con- 
ditions have  upon  the  prognosis. 

The  only  remaining  class  of  diseases  to  which  I  need 
allude  are  those  affecting  the  haemopoietic  system.  In 
several  of  the  diseases  affecting  this  system,  such  as  purpura, 
scorbutus,  haemophilia,  pernicious  anaemia,  and  even  simple 
anaemia,  albuminuria  is  not  infrequent,  and  in  some  of 
them  there  is  actual  haemorrhage  from  the  kidney  or  the 
urinary  tract.  In  such  cases  the  prognosis  is  simply  that  of 
the  general  disease.  If  the  morbid  process  can  be  cured,  so 
will  the  albuminuria  and  haematuria.      In  such  cases  we  are, 


192  ALBUMINURIA. 

generally  at  least,  justified  in  regarding  the  renal  symptom 
as  a  blood  albuminuria,  which  will  be  cured  by  improving 
the  state  of  the  blood  or  of  the  glands  which  act  upon  it. 
When  there  is  superadded  a  degree  of  renal  inflammation, 
the  prognosis  is,  of  course,  influenced  thereby. 


LECTURE    XIV. 

x     ON  DIET  IN  ALBUMINURIA. 

Introduction.—  Production  of  Albuminuria  by  Diet. — Evidence  of 
Stokvis,  Lehmann,  Lauder  Brunton,  Maguire,  Claude  Pernarcl, 
and  Others. — Experiments  with  Egg  Diet;  Cheese;  Walnuts.- — 
Diet  in  Bright' s  Disease. —  Views  of  Dickinson  and  Partels. — 
Experiments. —  Various  Diets. — Pesults  in  Bright' s  Disease  and 
Mixed  Forms  of  Albuminuria. — Alcohol. 

C\  ENTLEMEN, — I  purpose  to-day  to  bring  before  you  the 
question  of  the  influence  of  diet  on  the  different 
varieties  of  albuminuria.  It  is  a  subject  which,  although 
often  and  carefully  studied,  is  well  worthy  of  further  investi- 
gation, and  I  shall,  after  indicating  the  views  generally  held 
by  the  profession,  bring  under  your  notice  the  results  of 
some  observations  which,  with  the  aid  of  my  resident 
physicians,  Drs.  Gulland  and  Pirie,  I  have  made  with  the 
view  of  testing  the  accuracy  of  current  opinion.  We  have 
sought  to  throw  some  additional  light  upon  the  question 
of  the  possibility  of  producing  albuminuria  by  diet  in 
persons  whose  kidneys  were  healthy,  and  as  to  the  effect 
of  various  forms  of  diet  in  patients  affected  with  albu- 
minuria. 

I  shall  speak  first  of  the  production  of  albuminuria  by 
diet.  The  facts  with  which  you  are  already  familiar  regard- 
ing the   frequent   occurrence   of  slight,   and  the  occasional 

occurrence   of  marked  albuminuria   after  meals  in   healthy 

193  o 


194  ALBUMINURIA. 

people,  have  prepared  you  to  expect  that  interesting 
results  might  be  obtained  by  means  of  experiments  on  diet. 
We  have  seen  that  in  certain  individuals  the  mere  ingestion 
of  food  of  whatever  kind  is  followed  by  albuminuria,  and 
that  in  others  particular  kinds  of  food  produce  this  effect, 
while  most  articles  of  diet  do  not.  Precise  experiments  have 
been  made,  especially  with  regard  to  the  influence  of  egg- 
albumen,  with  the  view  of  ascertaining  whether  that  sub- 
stance introduced  into  the  system  in  large  quantity  induces 
albuminuria,  what  the  variety  of  albumen  is  when  albuminuria 
does  appear,  in  what  condition  the  egg-albumen  must  be  intro- 
duced, and  by  what  channels  it  must  enter  the  circulation. 

The  experiments  of  many  observers,  of  whom  I  shall 
mention  Stokvis(3e)  (whose  work  I  have  always  found 
careful,  and  his  conclusions  trustworthy),  showed  that  the 
injection  of  egg-albumen  into  the  veins  of  animals  invariably 
produces  albuminuria,  while  the  injection  of  serum-albumen 
of  an  animal  of  the  same  species  produces  no  such  result, 
unless  the  quantity  is  such  as  to  produce  a  signal  rise  in  the 
blood- pressure  ;  and  in  these  experiments  it  was  found  that 
egg-albumen  appears  as  such  in  the  urine,  so  that  it  mani- 
festly passed  out  of  the  system  unchanged. 

It  may  also  be  accepted  as  demonstrated  that  the  injection 
of  egg-albumen  into  the  rectum  is  followed  by  a  similar 
albuminuria. 

But  as  to  the  effect  of  introducing  it  into  the  stomach 
there  is  more  doubt.  Thus,  it  may  be  introduced  either  in 
its  natural  condition  or  coagulated  by  cooking,  and  it  is 
necessary  to  distinguish  the  results  of  each  method.  We, 
of  course,  set  aside  the  cases  in  which,  from  an  idiosyncrasy, 
the  ingestion  of  eggs  is  always  followed  by  constitutional  dis- 
turbance, with  derangement  of  the  stomach,  and  sometimes 
albuminuria.  Apart  from  such  cases,  considerable  difference 
of  opinion  exists  as  to  the  facts.     Senator (20)  states  that  the 


EFFECTS    OF    EGG    DIET.  195 

investigations  of  Lehmann,  Stokvis,  and  Creite  show  beyond 
doubt  that  egg- albumen  is  really  excreted  as  such,  and  that 
in  the  majority  of  cases  the  albuminuria  disappears  when  it  is 
completely  excreted,  the  investigations  having  been  performed 
on  the  observers  themselves,  on  other  persons,  or  on  dogs  and 
rabbits.  Dr.  Coats (116)  expressed,  in  1884,  the  same  opinion, 
and  quoted  the  experiments  of  Nussbaum  to  show  that  egg- 
albumen  (however  introduced  into  the  system)  passes  out 
by  the  glomerular  tufts,  which  retain  the  serum-albumen. 
Dr.  Lauder  Brunton (117)  failed  to  produce  albuminuria  in  him- 
self by  swallowing  six  raw  eggs  in  succession,  but  violent 
headache  and  sickness  were  produced  ;  while  D'Arcy  Power,(117) 
on  the  other  hand,  succeeded  in  producing  albuminuria  in 
this  way.  Regarding  the  explanation  of  the  albuminuria 
thus  produced,  these  authors  remark  that  "it  is  only  when 
the  digestive  powers  are  overtaxed — as  by  swallowing  many 
raw  eggs  together,  or  deranged  so  as  to  digest  the  food  par- 
tially but  not  completely — that  such  an  event  occurs."  Dr. 
Maguire,(M)  in  his  able  paper  upon  the  albumens  of  the  urine, 
states  that  he  failed  to  produce  albuminuria  by  swallowing 
the  whites  of  twelve  raw  eggs,  a  slight  headache  being  the 
only  effect  produced.  He  rightly  points  out  that  the  severe 
digestive  disturbance  indicated  by  diarrhoea,  and  the  appear- 
ance of  bile  in  the  urine,  which  was  produced  in  the  animals 
fed  by  Stokvis  for  several  days  upon  raw  egg-albumen,  may 
account  for  the  albuminuria,  and  he  doubts  whether  observers 
have  taken  sufficient  care  to  ascertain  whether  egg-albumen 
or  albumen  in  another  form  appeared  in  the  urine.  Dr. 
Dobradin (118)  found  no  albumen  in  his  own  urine  after  he  had 
eaten  nineteen  raw  eggs  in  thirty-six  hours.  These  remarks 
apply  to  the  result  of  dieting  with  raw  eggs.  But  Claude 
Bernard (U9)  and  (I  suppose)  others  have  found  that  albuminuria 
may  be  produced  by  eating  large  numbers  of  cooked  eggs. 
This  of  course  stands  on  a  different  footing  from  the  experi- 


196  ALBUMINURIA. 

ments  made  with  uncooked  eggs,  for  however  the  latter 
might  be  absorbed  into  the  system  unchanged,  the  former 
must  necessarily  be  digested. 

As  our  information  upon  this  matter  seemed  to  me  some- 
what unsatisfactory,  I  thought  it  well  to  institute  some 
experiments  on  the  point.  I  selected  for  the  purpose  four 
individuals  whose  urine  showed  no  albumen  even  when  tested 
with  picric  acid,  and  whose  condition  offered  no  objection  to 
such  a  trial  being  made.  In  the  first  case — one  of  locomotor 
ataxia — the  patient  took  ten  raw  eggs  daily,  in  addition  to  his 
ordinary  diet,  for  a  period  of  nine  days.  In  two  days  from 
the  commencement  albumen  appeared.  It  was  not  in  large 
quantity,  but  quite  sufficient  to  be  demonstrated  by  picric 
acid.  On  two  occasions  it  was  demonstrable  with  nitric  acid, 
and  on  each  of  them  the  addition  of  excess  of  the  acid  re- 
dissolved  the  coagulum,  showing  that  it  was  not  egg-albumen, 
but  blood- albumen  that  was  present.  The  albumen  persisted 
from  the  second  day  to  the  end  of  the  experiment,  but  dis- 
appeared on  the  day  in  which  the  eggs  were  stopped.  In 
the  second  case — one  of  mitral  incompetence — nine  eggs 
were  given  daily  for  a  period  of  seven  days.  Albumen 
appeared  on  the  first  day,  persisted  throughout  the  experi- 
ment, and  disappeared  when  the  eggs  were  discontinued. 
Although  distinct  with  picric  it  never  showed  with  nitric 
acid.  In  the  third  case — one  free  from  organic  lesion — ten 
eggs  were  given  daily  for  three  days  in  addition  to  the 
ordinary  diet.  On  the  first  and  third  days  albumen  was 
distinct  with  picric  acid.  On  the  second  day  it  was  in 
such  quantity  as  to  be  shown  with  nitric  acid,  and  in  this 
case  also  the  opacity  readily  disappeared  when  an  excess  of 
the  reagent  was  used.  In  the  fourth  case — one  of  chorea — 
the  eggs  were  not  well  borne  by  the  stomach  ;  only  three 
were  taken,  and  the  experiment  was  continued  only  for  three 
days.      But  in  it  also  albumen  showed  itself  with  picric  acid 


EFFECTS    OF    EGG   DIET.  197 

on  the  third  day,  and  disappeared  when  the  patient  resumed 
his  ordinary  diet. 

The  results  of  these  experiments  go  to  confirm  the  im- 
pression that  the  introduction  of  raw  egg-albumen  into  the 
stomach  induces  albuminuria  ;  that  the  albumen  is  always  in 
small  quantity  ;  that  it  disappears  when  the  ordinary  diet  is 
resumed  ;  and  that  it  is  not  egg- albumen,  but  serum- albumen 
which  is  discharged.  Explanations  of  this  kind  of  albumin- 
uria on  the  theory  of  absorption  of  egg-albumen  as  such  into 
the  blood,  and  its  discharge  from  the  kidneys,  must  be  set 
aside,  and  with  it  also  the  speculation — so  far  as  this  ques- 
tion is  concerned — as  to  the  minute  size  of  the  molecules  of 
egg-albumen  and  its  greater  transfusibility.  In  these  experi- 
ments also  it  was  clear  that  the  albuminuria  was  not  a  result 
of  gastric  disturbance  produced  by  diet,  for  no  gastric  dis- 
turbance manifested  itself  in  the  cases  in  which  the  albumin- 
uria was  most  distinct.  Two  suggestions  may  be  offered  by 
way  of  explanation.  One  is,  that  owing  to  the  large  amount 
of  albumen  digested  and  absorbed,  the  blood  becomes  sur- 
charged with  that  ingredient,  and  some  of  the  excess  escapes 
by  the  kidneys.  The  other  explanation  stands  in  relation  to 
some  recent  investigations  on  allied  topics  by  Dr.  Kalfe,(51) 
Dr.  Noel-Paton,(120)  and  Dr.  Thomas  Oliver (121)  of  Newcastle. 
Dr.  Kalfe  has  shown  in  an  interesting  way  the  relation  of 
functional  albuminuria  and  hemoglobinuria  to  the  rate  of 
destruction  of  the  red  blood- corpuscles,  and  of  the  forma- 
tion of  urea.  Dr.  Noel-Paton  has  brought  out  some  of  the 
relations  which  exist  between  bile  secretion  and  urea  forma- 
tion. Dr.  Oliver  has  shown  that  the  urea  is  mainly  formed 
from  the  red  blood-corpuscles,  and  that  the  most  active 
period  of  urea  formation  is  when  the  liver  is  actively  secret- 
ing during  digestion.  It  seems,  in  the  light  of  all  these 
observations,  reasonable  to  suppose  that  in  our  experiments 
the  liver  was  stimulated  to  excessive  activity  owing  to  the 


198  ALBUMINURIA. 

excessive  amount  of  proteids  ingested,  that  thus  the  red 
blood-corpuscles  were  more  rapidly  destroyed,  and  that  the 
albumen  liberated  from  them  not  being  all  transformed  into 
urea  was  in  part  discharged  by  the  kidneys.  This  suggestion 
receives  some  confirmation  from  the  facts  which  we  observed 
in  regard  to  the  urea  discharge.  In  the  first  case  there  was 
a  marked  increase  in  its  amount  after  the  eggs  were  com- 
menced, followed  by  as  marked  a  fall  on  the  day  after 
ordinary  diet  was  resumed.  In  the  second  case  the  urea  was 
over  the  normal,  except  on  one  day,  during  the  whole  time 
that  the  eggs  were  taken,  and  for  two  days  afterwards.  Then 
followed  a  fall  to  the  normal  amount.  In  the  third  case  also 
an  increase  of  urea  was  distinct,  although  the  results  were 
less  striking  from  the  brevity  of  the  experiment.  In  the 
fourth  case  the  effects  were  doubtful,  but  it  will  be  remem- 
bered that  only  three  eggs  were  taken  daily. 

Apart  from  the  egg-albumen  diet,  I  was  anxious  to  get 
information  as  to  other  food  substances  which  are  supposed 
to  stand  in  close  relationship  to  albuminuria.  Eemembering 
the  prominence  which  Sir  Robert  Christison's (94)  remarks  in 
regard  to  cheese  had  given  to  that  substance  in  this  respect, 
I  arranged  to  give  a  good  supply  of  it  to  twenty  healthy 
boys,  and  to  test  their  urine  before  and  after  its  use.  I 
show  you  in  tabular  form  the  results  brought  out  by  this 
experiment.  Two  ounces  of  Cheddar  cheese  were  taken  by 
each  boy  soon  after  twelve  o'clock,  breakfast  having  been 
taken  at  eight,  and  a  specimen  of  urine  passed  before  taking 
the  cheese  was  compared  with  one  voided  shortly  afterwards. 


[Table  xxviii. 


EFFECTS    OF    CHEESE    AND    WALNUTS. 


190 


Table  XXVIII. — Showing  the  effect  of  Cheese  on  the  Incidence 
of  Albuminuria  in  20  Presumably  Healthy  Boys. 


Before  Cheese. 

After,  Cheese. 

Number. 

With  Nitric  With  Picric 
Acid.             Acid. 

Total. 

With  Nitric 
Acid. 

With  Picric 
Acid. 

Total. 

20 

1 

6 

7 

0 

G 

6 

You  observe  that  while  one  showed  albumen  with  nitric 
acid  (only  a  trace)  and  six  with  picric  before  the  repast, 
none  showed  it  with  nitric  and  six  with  picric  afterwards  ; 
but  the  latter  six  did  not  exactly  correspond  to  the  former, 
for  one  boy  who  showed  no  albumen  before  the  repast  showed 
it  afterwards.  The  boy  who  showed  it  with  nitric  acid 
before,  showed  only  with  picric  acid  afterwards.  Two  others 
who  had  had  a  distinct  picric  acid  reaction  before,  showed 
only  the  faintest  trace  afterwards.  And  in  one  it  disappeared 
in  the  later  though  present  in  the  first  specimen.  These 
results  point  to  the  conclusion  that  cheese,  when  eaten  in 
reasonable  amount,  has  little  or  no  effect  in  producing 
albuminuria  in  healthy  people.  Those  in  whom  it  has  this 
effect  must  be  regarded  as  the  subjects  of  idiosyncrasy.  It 
is  possible  that  the  large  proportion  of  albuminuria  in  the 
twenty  boys  before  the  cheese  was  eaten  was  due  to  the 
effect  of  the  breakfast  not  having  yet  passed  off  at  the  time 
of  the  earlier  micturition. 

I  thought  also  that  it  might  be  well  to  try  the  effect  of 
walnuts  in  this  respect,  and  accordingly  gave  ten  pre- 
sumably healthy  boys  six  walnuts  each.  They  were  taken 
apart  from  meals,  and  a  specimen  of  urine  was  obtained 
before  and  some  time  after  they  had  been  taken.  The  result 
showed  that  while  before  taking  the  walnuts  one  showed 
albumen  with   nitric  acid   and  other  two  with  picric  acid, 


200  ALBUMINURIA. 

afterwards  a  different  one  showed  with  nitric  acid  who  had 
only  showed  with  picric  before,  and  other  three  showed 
with  picric  acid.  Thus  there  was  an  increase  on  the  whole 
number  showing  albumen.  The  boy  who  had  shown  with 
nitric  acid  before,  showed  only  with  picric  afterwards. 
From  this  experiment  it  appears  that  the  use  of  such 
articles  of  diet,  even  in  moderate  quantity,  may  suffice  to 
produce  albuminuria  in  some  individuals,  and  certainly,  at 
all  events,  it  proved  more  active  than  cheese.  The  six 
walnuts  weighed,  without  their  shells,  only  five  drams,  and 
yet  the  effect  was  very  distinct. 

Our  general  conclusion  as  to  this  part  of  our  subject  is, 
that  while  the  ingestion  of  food  has  been  shown  frequently 
to  produce  albuminuria  from  idiosyncratic  peculiarities, 
particular  articles  of  diet  induce  it  in  some  people,  and  while 
we  may  succeed  in  inducing  it  by  the  use  of  special  articles 
of  diet,  yet  the  quantity  of  albumen  is  usually  minute,  and 
it  has  little  tendency  to  persist  after  the  resumption  of 
ordinary  food. 

Proceeding  now  to  consider  the  second  part  of  our  sub- 
ject, I  shall  speak  first  of  the  diet  in  Bright 's  disease.  The 
profession  is  for  the  most  part  agreed  as  to  what  is  most 
suitable.  I  shall  content  myself  with  quoting  the  statements 
of  one  or  two  of  the  most  judicious  writers  on  the  subject. 
Dr.  Dickinson (122)  says  that  in  the  inflammation  of  the  tubules 
spare  diet,  with  plenty  of  water,  abundance  of  milk,  and 
sufficiency  of  light  broth  or  beef-tea,  is  best.  In  cirrhosis 
the  food  should  be  as  non-nitrogenous  as  is  consistent  with 
the  proper  nutrition  of  the  patient.  Purely  vegetable  diet 
has  not  succeeded,  and  the  anaemic  tendencies  forbid  a  non- 
nutritious  regimen,  but  the  patient  should  be  kept  upon  the 
smallest  amount  of  food  on  which  he  can  thrive.  In  the 
waxy    disease    he    recommends    that    the    diet     should    be 


DIET    IN    BRIGHT'S    DISEASE.  201 

generous  and  varied,  and  that  extra  supplies  of  beef-tea 
and  Liebig's  extract  should  be  given  for  the  sake  of  the 
saline  constituents. 

The  late  Professor  Bartels,(123)  of  Kiel,  recommended  in  acute 
tubular  inflammation  a  milk  diet,  with  all  its  possible 
modifications,  as  the  ideal  bill  of  fare.  If  the  digestive 
organs  and  the  appetite  permitted,  he  recommended  a  more 
solid  diet,  consisting  of  easily  digested  meats,  light  vegetable 
food,  and  good  bread.  In  chronic  inflammation  of  the 
tubules  the  milk  seemed  to  him  more  essential,  especially 
where  there  was  loss  of  appetite,  which  he  ascribed  to  oedema 
of  the  gastric  mucous  membrane.  In  cirrhosis  of  the  kidney 
he  advises  to  sustain  the  strength  by  abundant  meat,  milk, 
and  mixed  vegetable  dietary.  In  waxy  cases  he  praises  the 
effect  of  vigorous  diet  of  meat  and  milk  with  the  use  of  good 
wine. 

It  were  tedious  for  me  to  quote  to  you  the  very  similar 
conclusions  of  Johnson,  Roberts,  Rosenstein,  Purdy,  and 
other  writers.  You  may  assume  that  the  two  whom  I 
have  quoted  represent  the  views  generally  held  by  judicious 
practitioners. 

It  will  be  apparent  from  the  results  which  I  have  now 
to  lay  before  you  that  these  views  are  generally  confirmed 
by  our  observations.  I  wish  that  the  importance  of  our 
results  had  been  more  commensurate  with  the  amount  of 
time  and  labour  expended  upon  them. 

The  diets  which  we  employed  were  five  in  number  : — (1) 
ordinary,  (2)  large,  (3)  milk,  (4)  low,  (5)  low  diet  with 
eggs.  The  annexed  tables  show  the  composition,  weight, 
and  the  amount  of  carbon  and  of  nitrogen  contained  in 
each  : — 


[Table  xxix. 


202 


ALBUMINURIA. 


Table  XXIX. — Ordinary  Diet. 


Ounces. 

Carbonaceous. 

Nitrogenous. 

Total. 

Meat  (minced  collops), 

8 

1-2 

1-61 

2-81 

Bread, 

12 

6-18 

1-26 

7-44 

Potatoes,     . 

12 

2-94 

0-30 

3-24 

Sugar, 

2 

2-00 

o-oo 

2-00 

Milk,. 

24 

1-92 

1-08 

3-00 

Butter, 

1 

1-00 

o-oo 

1-00 

Total, 

59 

15-24 

4-25 

19-49 

Table  XXX. — Large  Diet. 


Ounces. 

Carbonaceous. 

Nitrogenous. 

Total. 

Meat  (minced  collops), 

16 

2-40 

3-22 

5-62 

Bread, 

16 

8-84 

1-08 

9-92 

Potatoes,    . 

12 

2-94 

0-30 

3-24 

Sugar, 

2 

2-00 

o-oo 

2-00 

Milk, 

24 

1-92 

1-08 

3-00 

Butter, 

Total, 

1 

1-00 

o-oo 

1-00 

24-78 

71 

19-10 

5-68 

Table  XXXI.— Milk  Diet. 


Ounces. 

Carbonaceous. 

Nitrogenous. 

Total. 

Milk, 

80 

6-4 

36 

lO'O 

Table  XXXII.  —  Low  Diet. 


Ounces. 

Carbonaceous. 

Nitrogenous. 

Total. 

Bread, 
Potatoes,   . 
Sugar, 
Milk, 
Butter, 

Total, 

12 
24 

4 
24 

1 

6-18 
5-88 
4-00 
1-92 
1-00 

1-26 
0-60 

o-oo 

1-08 

o-oo 

7-44 
6-48 
4-00 
3-00 
1-00 

65 

18-98 

2-94 

21-92 

DIET    IN    NEPHRITIS. 


203 


Table  XXXIII. — Low  Diet  with  Eggs. 


Eight  raw  eggs, 


Ounces. 


144 


Carbonaceous. 


4-35 


Nitrogenous. 


5-8 


(Otherwise  as  in  Table  XXXII.) 


Total. 


10-1E 


The  following  are  short  notes  of  the  cases,  in  regard  to 
which  the  points  determined  were  :  the  weight  of  the 
patient,  the  daily  amount  of  urine,  its  specific  gravity,  the 
amount  of  urea,  and  the  amount  of  albumen  in  grammes  per 
litre  as  determined  by  Esbach's  method. 


I.  Inflammatory  Bright's  Disease. 

T.  T.,  set.  19,  a  gardener,  was  admitted  to  Ward  XXII.  on 
24th  December,  1886,  suffering  from  dropsy,  and  had  been  ill 
for  eight  weeks.  Early  in  October  the  patient  had  scarlet  fever. 
During  desquamation  he  went  out  and  was  exposed  to  cold. 
He  then  took  dropsy,  with  diminution  of  urine,  and  the 
other  ordinary  features  of  post-scarlatinal  nephritis.  As  the 
symptoms  did  not  yield,  he  was  sent  to  the  Infirmary. 

In  this  patient  trial  was  made  of  the  effects  of  ordinary 
diet  for  seventeen  days,  milk  diet  for  eight  days,  and  low  diet 
for  eight  days.  The  analyses  showed  that  each  of  the  three 
brought  out  essentially  the  same  result,  both  in  respect  of  the 
urea  and  the  albumen.  I  should  not  have  considered  it  right 
to  give  the  large  diet  to  this  patient,  as  it  might  have  proved 
irritating  to  the  kidneys. 

L.  M.3  set.  52,  an  unmarried  woman,  was  admitted  to  Ward 
XXV.  on  7th  December,  1886,  suffering  from  subacute  inflam- 
matory Bright's  disease.  She  had  been  ill  for  about  a 
month.  Her  chief  complaints  were  of  dropsy  and  debility. 
Her  urine  was  on  admission  22  ounces  in  the  24  hours.  It 
was  of  pale  straw  colour,  its  specific  gravity  1016  ;   it  con- 


204  ALBUMINURIA. 

tained  1 31/12  grains  of  urea  and  1'25  grammes  of  albumen 
per  litre,  and  deposited  a  few  blood- corpuscles  and  a  good 
many  granular,  epithelial,  and  hyaline  tube  casts.  The 
dropsy  was  distinct,  although  not  severe.  The  pulse  was 
regular  and  rather  tense,  but  there  was  a  systolic  murmur 
most  audible  in  the  aortic  area.  In  this  case  it  was  some- 
what difficult  to  judge  of  the  effects  of  the  diet,  as  the  patient 
was  making  throughout  steady  although  rather  slow  progress 
towards  recovery.  The  ordinary,  the  large,  the  milk,  and  the 
low  diets  were  tried  in  succession,  and  we  came  to  the  con- 
clusion that  the  two  latter  did  better  with  her  than  the  first 
two,  and  that  the  low  diet  was  the  best  of  all.  While  under 
ordinary  diet  she  was  passing  4  6 §  ounces  of  urine,  contain- 
ing 270'7  grains  of  urea,  and  1'75  grammes  of  albumen  per 
litre  ;  under  the  large  she  passed  5(H  ounces,  containing 
2 47 '5  grains  of  urea,  and  about  0-2  gramme  of  albumen  per 
litre  ;  under  the  milk  she  passed  48  ounces  of  urine,  with 
301*4:  grains  of  urea,  and  about  O'l  gramme  of  albumen  per 
litre  ;  and  under  the  low  diet  she  passed  48  J  ounces  of 
urine,  187 '5  grains  of  urea,  and  only  once  a  trace  of  albu- 
men. She  also  gained  weight  slightly  while  taking  the  low 
diet. 

K.  M.,  set.  45,  a  carter,  was  admitted  to  Ward  XXII.  on  15th 
December,  1886,  suffering  from  chronic  inflammation  of  the 
kidneys,  chiefly  affecting  the  tubules,  but  probably  to  some 
extent  the  stroma  also.  The  quantity  of  urine  was  about  5  2 
ounces,  of  dark  colour,  specific  gravity  1018,  containing  303  5 
grains  of  urea,  and  albumen  in  the  proportion  of  3  2  grammes 
per  litre.  There  was  a  considerable  amount  of  dropsy,  some 
tension  of  pulse,  sclerosis  of  arteries,  the  heart  was  not 
enlarged,  and  there  was  a  slight  systolic  murmur  in  the 
aortic  area.  In  this  case  the  ordinary,  the  milk,  and  the  low 
diets  were  used.  Under  their  use  no  difference  emerged  as 
to  the  amount  of  urine,  or  the  specific  gravity,  and  there  was 


DIET    IN    CIRRHOSIS.  205 

very  little  effect  on  the  urea.     But  the  albumen  diminished 
under  the  milk,  and  continued  to  do  so  under  the  low  diet. 

It  is  clear  that  these  experiments,  although  I  may  claim 
that  they  were  carried  out  with  extreme  care,  were  far  from 
sufficient  of  themselves  to  warrant  our  arriving  at  any  general 
conclusion.  Still  they  afford  some  support  to  the  view 
generally  held  by  the  profession,  that  milk  diet  or  low  diet 
are  better  suited  to  such  cases  than  ordinary  or  ample  diet. 

II.  Cirrhotic  Bright's  Disease,  with  Inflammatory 

SUPERADDED. 

S.  R,  set.  40,  a  waiter  in  an  hotel,  was  admitted  to  Ward 
XXII.  on  15th  January,  1887,  suffering  from  cirrhosis  of  the 
kidneys,  with  some  degree  of  inflammation  of  the  tubules 
superadded.  He  was  passing  at  the  time  of  his  admission 
only  15  ounces  of  urine.  Its  specific  gravity  was  1036.  It 
contained  serum-albumen,  globulin,  and  a  trace  of  peptone, 
144  grains  of  urea,  and  hyaline,  granular,  and  fatty  casts. 
The  dietetic  experiments  were  commenced  on  18th  January, 
and  he  had  ordinary  and  milk  diet  in  succession  for  periods 
of  six  days  respectively.  No  effect  was  discernible  upon  the 
quantity  of  urine  or  of  urea,  and  the  albuminuria  was 
certainly  not  diminished  by  the  milk  diet. 

III.  Pure  Cirrhosis  of  the  Kidneys. 

J.  S.,  set.  26,  a  joiner,  was  admitted  to  Ward  XXII.  com- 
plaining of  loss  of  sight  and  headache.  His  case  has  been 
referred  to  in  one  of  my  earlier  lectures,  and  I  shall  now 
say  only  that  it  presented  all  the  features  characteristic 
of  renal  cirrhosis.  His  urine  was  in  good,  although  not 
excessive,  quantity.  It  contained  albumen  and  a  few  casts, 
with  about  150  grains  of  urea  in  the  24  hours.  The 
heart   was   hypertrophied,  the   pulse  firm  and   tense.      The 


206  ALBUMINURIA. 

blood  was  somewhat  poor  in  corpuscles,  and  the  eyes  showed 
the  characteristic  features  of  albuminuric  retinitis.  It  was 
clear  that  the  renal  disease  was  advanced.  Ordinary,  large, 
milk,  low,  and  egg  diet  were  given  in  succession,  and  it  was 
found  that  with  the  first  four  of  these  the  urine  remained  in 
all  respects  unchanged.  In  trying  the  egg  diet,  I  gave  eight 
raw  eggs  daily,  in  addition  to  the  ordinary  allowance  of  low 
diet.  The  quantity  of  urine  was  unaltered ;  its  specific 
gravity  became  somewhat  higher.  The  urea  showed  a 
decided  increase  during  the  first  four  days  that  the  eggs  were 
used,  and  diminished  again  in  the  later  three  days  of  the 
observation.  The  albuminuria  showed  a  relative  increase 
during  the  first  two  days,  and  during  the  rest  of  the  time  the 
amount  was  about  the  same  as  it  had  been  before  the  experi- 
ment commenced. 

In  the  cases  of  T.  M.  and  R  D.  F.,  both  suffering  from 
cirrhosis  of  kidney,  the  egg-diet  was  carefully  tried,  and  no 
material  change  resulted. 

From  these  and  other  observations  I  am  inclined  to  think 
that  in  the  cirrhotic  form  of  Bright's  disease  the  diet  is  a  less 
important  element  than  it  is  in  the  tubular  inflammation. 

IV.  Waxy  or  Amyloid  Form  of  Bright's  Disease. 
I  have  not  had  opportunity,  since  entering  upon  the 
present  investigation,  of  carrying  out  an  elaborate  and  ex- 
tended series  of  observations  ;  but  by  the  kindness  of  Dr. 
James  Ritchie  I  have  had  it  in  my  power  to  ascertain  the 
effect  of  egg  diet  upon  a  well-marked  example  of  this  disease. 
The  patient,  a  young  lady,  was  suffering  from  chronic 
abscesses  connected  with  vertebral  disease,  and  had  for  some 
time  exhibited  the  ordinary  features  of  waxy  degeneration  of 
the  kidneys.  Six  raw  eggs  were  taken  daily  for  two  days,  in 
addition  to  her  ordinary  food.  The  urine  was  120  ounces 
before  the  eggs  were  taken,  and   100   ounces  on  the  second 


DIET    IN    FEBRILE    CASES.  207 

day  of  the  egg  diet.  Its  amount  of  urea  was  200  grains 
before  and  210  grains  after,  thus  showing  a  slight  increase, 
notwithstanding  the  diminution  of  urine.  The  albumen  was, 
before  the  eggs  were  used,  3*8  grammes  per  litre,  or  199#5 
grains  in  the  24  hours,  afterwards  7 '2  grammes  per  litre,  or 
315  grains  in  the  24  hours.  This  increase  of  albumen  was 
very  marked,  and  it  was  found  not  to  be  egg-albumen  but 
ordinary  serum-albumen  which  was  present. 

In  a  doubtful  case  of  waxy  disease  complicated  with  other 
renal  disorders  a  succession  of  ordinary,  large,  milk,  and  low 
diets  was  tried,  and  we  satisfied  ourselves  that  there  was  no 
effect  upon  the  amount  of  urine,  its  specific  gravity,  or  the 
discharge  of  urea.  With  regard  to  the  albumen,  however,  it 
was  found  that  the  use  of  the  large  diet  was  attended  by  some 
increase,  and  the  low  diet  gave  a  diminution,  that  suiting  the 
patient  better  than  the  milk  diet. 

In  waxy  cases,  then,  so  far  as  my  evidence  goes,  I  am  in- 
clined to  think  that  the  good  nourishment  which  is  otherwise 
indicated  in  that  disease  is  not  contra-indicated  by  the  state 
of  the  kidneys,  even  although  their  vessels  appear  to  be  in  a 
condition  permitting  of  more  ready  transudation  of  albumen 
than  is  the  case  with  healthy  vessels. 

I  shall  speak  more  briefly  of  the  forms  of  albuminuria 
which  are,  comparatively  speaking,  not  dangerous  to  life. 
Some  of  them  may  be  indeed  dismissed  in  a  few  words. 

In  cases  of  febrile  albuminuria,  the  question  of  diet  is 
usually  of  little  moment,  but  in  some,  and  especially  in 
scarlet  fever,  there  is  a  special  liability  to  the  occurrence  of 
actual  inflammation  of  the  kidney,  and  there  is  no  doubt 
that  the  use  of  a  copious  diet  rich  in  nitrogenous  substances 
is  very  dangerous,  but  that  something  of  the  nature  of  low 
diet  or  milk  diet  is  best  for  such  fever  cases  during  con- 
valescence as  well  as  during  the  continuance  of  the  fever. 


208  ALBUMINURIA. 

The  albuminuria  due  to  heart  disease  is,  as  a  rule,  com- 
paratively slight,  and  in  the  presence  of  the  organic  changes 
in  the  circulatory  system,  scarcely  deserves  attention. 

As  to  the  forms  of  albuminuria  which  accompany  derange- 
ment of  the  digestive  system,  I  have  already  referred  to 
the  idiosyncratic  relations  of  some  individuals  to  particular 
articles  of  diet.  As  I  have  made  no  special  observations 
regarding  these  cases,  I  shall  merely  say  here  that  albumin- 
uria due  to  digestive  derangements  is  necessarily  influenced 
by  the  kind  of  food  which  produces  the  disturbance  in  each 
particular  case,  and  that  the  effect  of  different  diets  upon 
the  albuminuria  must  depend  on  the  effect  they  have  on  the 
digestive  derangement. 

Albuminuria  connected  with  nervous  disease  and  with 
glycosuria  also  demands  little  attention  in  this  respect. 
There  thus  remain  only  the  functional  and  accidental  groups 
for  consideration. 

As  to  the  four  great  varieties  of  functional  albuminuria 
— the  paroxysmal,  the  dietetic,  that  due  to  exercise,  and 
the  simple  persistent — the  first  requires  no  special  notice. 
Of  the  second,  it  is  obvious  that  each  individual  case  must 
be  studied,  and  the  diet  prescribed  for  the  patient  in 
accordance  with  what  may  seem  best  to  suit  his  individual 
peculiarities.  In  some  cases  referable  to  the  third  group — 
that  of  albuminuria  from  exercise — I  have  made  careful 
trial  of  different  kinds  of  food,  and  I  do  not  think  that 
much  difference  was  induced  by  it.  It  is  true  that  in 
the  case  of  the  young  lady  whose  case  is  given  in  detail 
in  the  eleventh  lecture  of  this  series,  there  was  a  relative 
diminution  of  albumen  when  she  was  under  the  milk  diet. 
But  the  diminution  was  merely  relative,  the  water  was 
increased  to  a  large  extent,  while  the  daily  discharge  of 
albumen  remained  unaltered.  I  have  had  opportunity 
during  the  present  summer  of  making  observations  as  to 


DIET    IN    FUNCTIONAL    CASES.  209 

the  effect  of  diet  in  a  case  which  I  regard  as  one  of 
simple  persistent  albuminuria.  The  patient  is  a  young 
man  of  twenty,  who  is  suffering  from  asthma,  bronchitis, 
and  backward  pressure  on  the  right  side  of  the  heart. 
Although  his  urine  is  always  albuminous,  it  shows  no 
tube  casts,  and  has  rather  an  excess  than  a  diminution  of 
urea.  He  has  also  no  evidence  of  the  usual  consecutive 
complications  met  with  in  true  renal  cases.  This  patient 
was  kept  upon  his  ordinary  diet  for  two  days.  He  then 
took  for  ten  days  ten  raw  eggs  in  addition  to  other  food. 
He  was  then  kept  upon  a  purely  milk  diet  for  seven  days, 
and  thereafter  his  ordinary  diet  was  resumed. 

The  egg  diet  had  no  effect  upon  the  quantity  of  urine. 
There  is  some  doubt  as  to  the  effect  on  the  urea  at  first, 
but  certainly  towards  the  end  of  the  period  of  experiment 
it  underwent  a  distinct  increase.  The  albumen  also  increased 
both  relatively  and  absolutely,  especially  towards  the  end 
of  the  experiment.  It  may  be  worthy  of  mention  that 
we  examined  four  specimens  of  the  water  daily — one  before 
breakfast,  one  after  it,  one  in  the  afternoon,  and  one  in 
the  evening — and  found  that  while  the  albumen  was  usually 
more  abundant  after  breakfast,  it  was  not  more  so  than 
one  usually  finds  apart  from  special  egg  dieting,  and  on 
some  days  there  was  no  increase  after  breakfast. 

The  milk  diet  increased  the  quantity  of  urine  considerably. 
The  urea  remained  as  high  as  it  had  been  at  the  end  of 
the  period  during  which  the  eggs  were  given — and  twice 
it  was  distinctly  higher.  The  albumen  was  on  one  day 
larger  than  on  any  previous  occasion,  but  on  the  whole  was 
less  than  it  had  been  under  the  egg  diet. 

During  the  first  five  days   on  which  ordinary   diet  was 

again  given  the  quantity  of  urine  was  about  the  same  as 

on  the  ordinary  diet  at  first,  the  urea  was  less  than  under 

the  milk  and  during  the  latter  period  of  the  egg  diet,  but 

p 


210  ALBUMINURIA. 

larger  than  under  ordinary  diet  at  first,  and  during  the 
first  part  of  the  egg  diet.  The  albumen  showed  a  relative 
increase  over  what  it  had  shown  under  the  milk — being 
at  least  in  as  large  a  proportion  as  during  the  egg  diet, 
but  the  absolute  amount  lost  during  the  twenty-four  hours 
showed  little  difference  from  what  it  had  done  during  the 
milk  diet. 

From  this  and  similar  cases  I  am  inclined  to  think  that 
little  is  gained  by  very  special  dieting  in  cases  of  this  kind, 
but  that  the  physician  should  keep  his  eye  upon  the  effect 
of  each  kind  of  food  in  each  individual  case. 

In  the  treatment  of  accidental  albuminuria,  diet  is  often, 
as  most  practitioners  well  know,  of  great  importance.  Above 
all,  in  cases  of  catarrhal  inflammation  of  the  urinary  tract, 
bland  and  milky  diet  is  to  be  recommended.  I  have  often 
seen  great  advantage  in  such  cases  from  the  adoption  of 
an  exclusively  milk  diet.  In  some  of  the  accidental  cases 
of  course  ordinary  dietetic  arrangements  are  best. 

As  to  the  use  of  alcoholic  stimulants,  I  think  that  it 
is  best  to  avoid  them  in  all  organic  renal  disease  and 
in  cases  of  inflammatory  accidental  albuminuria,  unless 
when  the  condition  of  the  circulation  or  nervous  system 
directly  requires  stimulation.  I  have  not  seen  alcohol  prove 
injurious  when  used  in  moderation  in  circulatory  albuminuria, 
nor  in  the  other  less  dangerous  groups. 


LECTUEE    XV. 

ON  THE  EFFECT  OF  MEDICINES  IN  ALBUMINURIA. 

Introductory. — Treatment  of  Nephritis.  —  Renal  Cirrhosis. — Waxy 
Degeneration.  —  Combined  Forms.  —  Febrile  Albuminuria.  — 
Albuminuria  from  Circulatory  Disease.  —  With  Alimentary 
Derangement.  —  With  Nervous  Disease.  —  With  Glycosuria.  — 
Functional  Albuminuria. — Accidental  Albuminuria. 

r\  ENTLEMEN, — Having  recently  laid  before  you  my  views 
as  to  the  dietetic  treatment  of  the  different  varieties  of 
albuminuria,  I  shall  devote  our  present  meeting  to  a  descrip- 
tion of  the  general,  and  especially  the  medicinal,  treatment  of 
each  of  the  forms, 

The  question  as  to  the  power  of  medicines  to  control  the 
discharge  of  albumen  with  the  urine  has  attracted  the  atten- 
tion of  many  observers,  and  numerous  drugs  have  enjoyed 
a  certain  reputation  with  some,  while  they  have  failed  in 
the  hands  of  others.  I  shall  give  you  as  briefly  as  possible 
a  general  idea  of  some  recorded  observations  on  this  question. 

Dr.   Lauder  Brunton,(124)   in   discussing    the   influence  of 

medicines  upon  albuminuria,  states  that  a  similar  effect  to 

that   of  temporary  ligature  of  the  renal   artery   (which,   as 

you   know,    produces    albuminuria),    may    be    produced    by 

causing  the  vessels  temporarily  to  contract  by  such  drugs 

as  digitalis.     He  and  Mr.  Power  found  that  the  urine  which 

was  first  secreted    after    the  temporary   arrest    induced  by 

digitalis  was  albuminous,  and  in   poisoning  by  strychnia   a 

similar   effect  is  noticed.      Such  drugs  as   cantharides   and 

211 


212  ALBUMINURIA. 

turpentine,  which  irritate  the  kidney,  may  produce  albu- 
minuria and  even  hsematuria.  Lead  and  mercury  produce 
albuminuria  by  inducing  chronic  interstitial  nephritis. 
Chlorate  of  potassium  and  glycerine  in  large  doses  produce 
hsematuria,  and  the  tubules  get  blocked  up  with  plugs  of 
broken-up  corpuscles. 

As  regards  the  much  more  important  question  of  the 
effects  of  medicines  in  diminishing  albuminuria,  Dr.  Brunton 
speaks  favourably  of  tannin  and  tannate  of  sodium,  which 
have  been  experimentally  found  useful  in  this  way  by 
Ribbert.  Arbutin,  the  active  principle  of  uva  ursi  appears, 
he  says,  to  be  still  more  efficacious,  and  fuchsin  has  a  similar 
action.  In  a  case  of  intermittent  albuminuria,(125)  which 
he  believed  to  be  due  to  imperfect  intestinal  digestion, 
arsenic  and  pancreatine  were  both  efficacious  in  stopping 
the  albuminuria.  Arsenic  has  also  been  found  useful  in 
this  respect  in  the  hands  of  others,  and  in  another  lecture  of 
this  series,  I  relate  a  case  in  which  chloride  of  ammonium 
was  similarly  efficacious.  He  also  points  out  the  value  of 
purgatives,  such  as  elaterium,  which  in  cases  of  renal  con- 
gestion, lessens  albuminuria  and  increases  the  flow  of 
urine. 

Dr.  Fothergill(126)  is  very  sceptical  as  to  the  value  of 
medicines  in  diminishing  albuminuria.  He  says,  "It  is 
questionable  how  far  the  drain  of  albumen  is  ever  sufficiently 
serious  to  endanger  life,  and  it  is  even  more  questionable  if 
the  drain  can  be  checked  by  astringents  unless  they  be 
ferruginous."  His  favourite  treatment  consists  in  warm 
baths,  warm  clothing  and  poultices,  plasters  and  cupping 
to  the  loins,  regulation  of  diet  ;  and  the  medicines  which  he 
prefers  are  cathartics,  containing  potash,  the  potassio-tartrate 
of  iron  in  buchu,  and  mercury  in  limited  doses,  the  last  of 
which,  he  says,  Dr.  Broadbent  has  found  very  useful  in 
removing   the   traces   of  albumen   which    often    persist    for 


TREATMENT    OF    ALBUMINURIA.  213 

a  long  time  towards  the  decline  of  inflammatory  Bright's 
disease  after  fever. 

Dr.  Allard  Memminger(127)  finds  that  in  Bright's  disease 
chloride  of  sodium  reduces  the  albuminuria,  increases  the 
urea  and  chlorides,  removes  oedema,  and  otherwise  improves 
the  patient. 

Dr.  Sydney  Ringer (128)  states  that  Dr.  George  Lewald  has 
found  that  lead  diminishes  to  some  extent  the  amount  of 
albumen  lost  in  twenty-four  hours  in  Bright's  disease,  while 
it  increases  the  amount  of  urine.  The  same  observer  has 
found  that  tannin  acts  in  a  similar  manner. 

Senator (20)  says  there  is  at  most  one  drug,  iodide  of 
potassium,  which  must  be  allowed  to  possess  a  certain 
amount  of  efficacy  in  some  forms  of  chronic  nephritis. 

One  of  the  most  careful  writers  on  the  subject  is  Dr. 
Saundby (129)  of  Birmingham,  who  has  made  an  elaborate  and 
valuable  series  of  observations  in  order  to  test  the  effect  of  a 
large  number  of  drugs  on  albuminuria.  He  made  a  careful 
quantitative  estimation  of  the  albumen  by  Esbach's  method, 
and  after  having  tried  all  or  nearly  all  the  important  drugs 
from  which  some  result  might  have  been  expected,  including 
alkalies,  astringents,  benzoates,  cardiac  tonics,  pilocarpine, 
turpentine  and  similar  remedies,  fuchsin,  cantharides,  iodide 
of  potassium,  iron  preparations,  and  purgatives,  he  says  that 
he  cannot  affirm  that  any  one  of  them  can  exercise  control 
over  the  quantity  of  albumen  lost  with  the  urine.  Some 
advantage  appeared  to  follow  the  use  of  certain  medicines, 
for  example,  alkalies  and  tannate  of  sodium  in  chronic  cases  ; 
nitro-glycerine  in  acute  cases.  Digitalis  and  other  heart 
tonics  increased  the  albumen.  So  also  did  iron  in  various 
forms.  Perchloride  of  mercury  in  very  minute  doses  (xoVo^ 
grain),  although  it  has  been  highly  praised,  was  found 
useless.  Purgatives  and  diaphoretics,  though  of  great 
value    in    treatment,   did    not   appear   directly  to    influence 


214  ALBUMINURIA. 

the   amount   of  albumen   excreted  in   chronic  Bright's   dis- 
ease. 

Sir  William  Roberts  and  Professor  Rosenstein  have  come 
to  the  same  general  conclusion  as  Dr.  Saunclby  as  regards 
the  inefficacy  of  drugs  in  diminishing  albuminuria,  and  I 
have  satisfied  myself  by  a  long  series  of  careful  observations 
that  we  have  no  right  to  credit  any  drug  with  the  power  of 
directly  diminishing  the  discharge  of  albumen. 

Passing  now  to  consider  the  treatment  of  the  different 
groups  of  cases,  I  shall  embody  the  results  of  a  series  of 
elaborate  and  prolonged  observations  made  for  me  mainly  by 
my  resident  physician  Dr.  Gulland,  and  partly  by  Dr.  Pirie. 
We  arranged  to  try  the  action  of  different  remedies  of  repute 
in  cases  of  different  groups ;  and,  after  determining  the 
amount  of  urine,  urea,  and  albumen  passed  on  an  average  by 
each  patient,  we  tried  different  drugs  in  succession,  noting 
the  effects  of  each,  in  each  particular,  of  the  cases.  The 
labour  involved  in  this  research  was  very  considerable,  but 
the  results  are  interesting,  and  in  some  respects  important. 

I  shall  speak  first  of  the  renal  inflammations. 

In  albuminuria  from  acute  or  subacute  inflammation  of 
the  kidneys  the  treatment  must  vary  according  to  the 
severity  of  the  disease.  Some  cases  get  well  without  any 
interference  ;  in  others,  the  life  is  saved  only  by  careful 
medication.  In  all  cases  the  patient  must,  in  the  early 
stage,  be  kept  in  bed.  The  action  of  the  skin  must  be 
favoured  by  warm  clothing,  while  the  diet  is  of  the  bland 
and  simple  kind  already  described.  When  dropsy  is  consi- 
derable, the  quantity  of  urine  is  almost  invariably  diminished, 
and  the  two  important!  indications  are  to  remove  the  one 
and  increase  the  other.  If  we  can  succeed  in  establishing 
diuresis,  we  attain  three  valuable  results — viz.,  we  clear  the 
tubules  of  inflammatory  materials  blocking  them  ;  we  relieve 


TREATMENT    OF    RENAL    DISEASE.  215 

the  blood  of  excrementitious  matter,  which  would  otherwise  be 
retained ;  and  we  drain  away  the  dropsical  fluid.  The  first 
of  these,  in  particular,  seems  to  me  to  be  of  great  importance ; 
for,  if  the  tubules  remain  blocked,  an  absorption  of  their  con- 
tents, molecule  by  molecule,  takes  place,  and  the  organ  shrinks 
in  corresponding  degree  ;  whereas,  if  the  tubules  are  cleared 
out,  opportunity  is  afforded  for  the  formation  of  new  epithe- 
lium, and  a  restoration  of  the  tubules  to  structural  and 
functional  health.  Some  writers  have  maintained  that  the 
use  of  diuretics  is  dangerous,  because  they  may  tend  to 
increase  the  renal  inflammation.  This  may  be  true  of  some 
diuretic  medicines,  but  it  certainly  is  not  true  of  all.  Diuresis 
may  be  obtained,  as  Dr.  Dickinson (122)  has  shown,  by  the 
administration  of  water,  two  or  three  pints  of  pure,  or,  best 
of  all,  distilled  water  being  taken  daily,  and  you  will  find 
that  milk  is  useful  in  this  way,  as  well  as  in  the  way  of 
supporting  the  nutrition.  But  medicines  are  often  required, 
and  digitalis  is  certainly  a  safe  and  non-irritating  diuretic. 
You  will  find  that  digitalis,  at  least  when  given  in  medicinal 
doses,  never  produces  albuminuria;  that  in  cardiac  cases  it 
often  leads  to  its  disappearance  ;  and  that  in  inflammations 
of  the  kidney  it  does  not  increase  the  albumen,  even  when  it 
is  exerting  an  active  diuretic  influence.  Strophanthus  and 
other  members  of  the  cardiac  tonic  group  may  also  be 
employed.  Saline  diuretics,  such  as  acid  tartrate  of  potassium 
and  acetate  of  potassium,  must  be  more  cautiously  employed 
during  the  acute  stages,  but  often  do  good  when  the  acute 
is  passing  into  the  chronic.  Combinations  of  these,  with 
broom-top  and  digitalis,  are  eminently  serviceable.  It  is 
better,  in  the  acute  stages,  not  to  use  juniper,  as  it  is  apt 
to  prove  too  irritating  ;  but  in  the  later  stages  both  it  and 
such  remedies  as  gin  and  copaiba  sometimes  act  when 
others  fail.  The  action  of  diuretics  may  be  helped  by  the 
use  of  nux  vomica.     Iron,  or  iron  combined  with  arsenic,  is 


216  ALBUMINURIA. 

frequently  of  great  service.  Much  relief  may  be  afforded  to 
the  kidneys  by  acting  upon  the  bowel.  Perhaps  a  free 
purge  sometimes  suffices  to  avert  renal  inflammation,  and 
certainly  salines  or  other  aperients  do  good  in  the  way  of 
eliminating  from  the  blood,  as  well  as  by  relieving  the 
affected  organ.  Acting  upon  the  skin  also,  is  of  the  utmost 
importance  in  such  cases.  The  use  of  pilocarpine,  of  hot 
vapour  baths  and  hot  air  baths,  as  well  as  of  milder  diapho- 
retic medicines,  often  give  relief.  Hot  poulticing  over  the 
loins,  and  sometimes  the  local  abstraction  of  blood  from  that 
region,  also  prove  serviceable.  Under  such  treatment  a  large 
proportion  of  these  cases  improves  ;  but,  although  improve- 
ment is  obtained,  the  albuminuria  frequently  tends  to  linger, 
and  many  attempts  have  been  made  to  overcome  that 
tendency.  Among  the  remedies  which  have  been  praised 
are,  tannic  acid,  tannate  of  sodium,  iron,  arbutin,  ergot,  bella- 
donna, and  hydrochlorate  of  rosaniline  (fuchsin).  I  have 
tried  very  carefully  a  number  of  these  medicines  in  some 
cases  of  the  kind,  determining  daily  the  amount  of  urine,  the 
amount  of  urea,  and  the  amount  of  albumen.  I  have  long 
ceased  to  have  faith  in  tannic  acid,  and  do  not  now  use  it, 
except  in  combination  with  sodium,  which  has  been  found 
useful  by  Saundby  and  other  careful  observers.  My  own 
experience  of  it  is  not  large,  but,  so  far  as  it  goes,  it  indicates 
that  in  this  form  of  albuminuria  it  produces  no  effect  either 
upon  the  discharge  of  albumen,  the  amount  of  water  passed, 
or  the  amount  of  urea. 

Iron  is  so  distinctly  beneficial  to  the  blood,  that  it  is  often 
employed  ;  and  in  at  least  one  case,  which  I  have  watched 
very  carefully,  there  was  no  doubt  that,  although  the  amount 
of  urine  and  of  urea  remained  unchanged,  the  albumen 
diminished.  Arbutin,  the  active  principle  of  uva  ursi,  has 
proved  in  my  hands  absolutely  inefficacious,  the  urine  re- 
maining unaffected  in  every  particular.     Ergot  suggests  itself 


TREATMENT    OF    RENAL    DISEASE.  217 

as  likely  to  prove  useful  by  contracting  the  blood-vessels ;  but 
it  has  failed  in  my  hands  to  influence  in  cases  of  this  kind 
either  the  total  amount  of  urine,  or  the  urea,  or  albumen. 
Many  years  ago  I  thought  that  I  obtained  good  results  from 
belladonna  in  some  cases  ;  but  my  recent  experience,  with 
careful  testing  of  the  urine,  has  scarcely  confirmed  the  very 
favourable  impression.  I  have  pushed  the  medicine  until 
dryness  of  the  mouth  resulted,  without  seeing  more  than  a 
slight  diminution  of  albumen.  The  hydrochlorate  of  ros- 
aniline,  if  carefully  and  perseveringly  used,  has  appeared  in 
some  of  my  cases  to  be  distinctly  useful ;  and  in  two  patients 
with  whom  I  tried  it,  determining  daily  the  amount  of  urine, 
urea,  and  albumen,  I  was  able  within  seven  days  to  satisfy 
myself  of  a  distinct  degree  of  diminution.  I  have  failed  to 
get  decided  benefit  from  iodide  of  potassium  in  this  respect, 
and  its  depressing  effect  is,  of  course,  to  be  dreaded  ;  but  it 
is  possible  that  it  may  be  useful  in  certain  chronic  condi- 
tions, where  the  process  is  passing  into  interstitial  contrac- 
tion. 

In  the  treatment  of  these  acute  cases,  apart  from  the 
question  of  the  albuminuria,  there  are  two  sets  of  urgent 
symptoms  which  often  endanger  life — ursemia  and  dropsy. 
For  acute  ursemia  the  best  treatment  is  to  act  freely  upon 
the  skin,  injecting  pilocarpin  subcutaneously,  applying  hot 
vapour  or  hot  air  baths,  while  keeping  the  convulsions  in 
check  by  chloroform,  chloral,  or  bromides.  In  such  cases  it 
is  also  well  to  act  upon  the  bowels  by  means  of  elaterium, 
jalap,  or  other  quickly  acting  hydragogue  cathartic,  and,  as 
soon  as  possible,  to  give  digitalis,  and  adopt  other  remedies 
for  relieving  the  kidneys.  Blood-letting  from  the  lumbar 
region  I  have  seen  sometimes  indicated,  and  occasionally 
useful.  Venesection  is  occasionally  helpful  in  extreme  cases, 
particularly  those  in  which  pregnancy  coexists  with  the  renal 
inflammation. 


218  ALBUMINURIA. 

Dropsy  is  best  met  by  diuretics,  purgatives,  and  diapho- 
retics ;  but  very  often,  when  these  fail,  life  may  be  saved  by 
mechanical  means.  Drawing  off  a  quantity  of  fluid  from  the 
pleura  or  from  the  abdomen  often  saves  the  patient ;  and  I 
have  known  one,  tapped  again  and  again,  saved  not  only 
from  the  immediate  danger,  but  actually  restored  to  health. 


In  cirrhosis  of  the  kidney,  no  medicine  is  as  yet  known  to 
have  the  power  of  altering  or  controlling  the  essential  morbid 
process.  All  that  we  can  hope  to  do  is  to  improve  the 
patient's  general  condition  by  relieving  certain  symptoms. 
It  is  true  that  a  great  authority,  the  late  Professor  Bartels  of 
Kiel,(123)  thought  that  iodide  of  potassium  was  able  in  some 
measure  to  control  the  morbid  process,  and,  partly  out  of 
respect  to  his  opinion,  I  sometimes  use  this  method  of  treat- 
ment, but  it  has  not  proved  serviceable  in  my  cases.  For 
the  relief  of  the  albuminuria  I  have  tried  carefully  the  effects 
of  belladonna,  hydrochlorate  of  rosaniline,  and  iron,  with 
entirely  negative  results.  Nitro-glycerine,  which  has  been 
praised  by  some,  has  been  followed  in  my  hands,  in  at  least 
one  well-marked  case,  by  a  slight  increase  in  the  amount  of 
albumen,  while  the  urine  and  urea  remained  unchanged.  In 
one  case  the  use  of  ergot  was  followed  by  a  diminution  in 
the  amount  of  albumen,  without  change  in  the  urine  or 
urea  ;  and  I  have,  on  at  least  one  occasion,  tried  the  effect 
of  full  doses  of  digitalis  in  a  case  of  this  kind,  in  which  I 
thought  it  was  not  contra-indicated,  and  I  found  no  altera- 
tion in  the  quantity  of  urine  or  of  albumen.  On  the  other 
hand,  much  relief  from  headache  may  be  obtained  by  the 
use  of  iron,  of  quinine,  of  chloride  of  ammonium,  also  of 
bromides,  belladonna,  cannabis  indica,  and  caffeine.  The 
excessive  vascular  tension  may  be  diminished  by  the  iodide 
of  potassium,  by  nitro-glycerine,  and  by  other  nitrites.  The 
aneemia  is  sometimes  improved  by  iron,  and,  still  more,  by 


TREATMENT    OF    RENAL    DISEASE.  219 

combinations  of  iron  with  quinine,  strychnine,  and  arsenic. 
Nutrient  remedies — various  preparations  of  malt,  cod-liver 
oil,  and  such- like — are  of  service  in  improving  the  general 
tone  of  the  patient,  and  retarding  the  inevitable  decay.  The 
uroemic  symptoms  are  generally  to  be  treated  as  in  the 
inflammatory  cases  ;  but  as  in  this  disease  they  are  more 
frequently  due  to  organic  changes  in  the  brain,  they  are,  on 
the  whole,  less  amenable  to  treatment. 


Waxy  disease  is  also,  in  its  essential  nature,  little  amenable 
to  the  action  of  medicines  ;  but  in  syphilitic  cases,  the  iodide 
of  potassium  or  of  starch,  and  in  all  cases  the  syrup  of  the 
iodide  of  iron,  may  possibly  be  useful.  The  albuminuria  has 
remained  unaffected  under  treatment  with  belladonna  and 
hydrochlorate  of  rosaniline.  I  have  seen  it  distinctly  increase 
while  ergot  was  being  given,  and  slightly  under  nitro-glycerine, 
neither  of  these  producing  any  effect  upon  the  amount  of 
urine  or  of  urea.  Iron,  in  the  form  of  tincture  of  perchloride, 
I  have  seen  followed  by  a  slight  diminution  of  the  daily  dis- 
charge of  albumen.  Cod-liver  oil,  various  malt  preparations, 
and  a  liberal  diet,  are  indicated  in  this  disease. 


In  the  mixed  forms  of  organic  renal  disease  the  treatment 
must  be  determined  according  to  the  preponderating  element. 
In  all  of  them,  whether  combined  or  not,  the  choice  of  climate 
is  of  much  importance.  When  it  is  possible,  these  patients 
should  avoid  cold  and  damp  districts.  It  is  well  for  them  to 
winter  in  the  South  of  Europe,  in  Algiers,  or  in  Egypt ;  and 
practitioners  in  high  altitudes,  such  as  Davos,  find  that  renal 
cases  should  not  try  treatment  there.  The  only  exception 
to  this  rule  is  afforded  by  purely  waxy  cases  which  have 
resulted  from  chronic  phthisis,  and  in  which  the  advantage 
to  be  derived  in  respect  of  the  pulmonary  disease  tells 
favourably  upon  the  kidney  also. 


220  ALBUMINURIA. 

Before  leaving  the  treatment  of  the  organic  renal  condi- 
tions, I  shall  say  a  word  or  two  regarding  the  treatment  of 
some  of  the  leading  complications.  In  gastric  catarrh,  care- 
ful regulation  of  diet,  feeding  the  patient  upon  milk,  soup,  or 
peptonised  preparations,  and  giving  them  in  small  quantities, 
frequently  is  the  first  indication.  The  use  of  bismuth,  or  of 
that  substance  with  a  very  small  dose  of  rhubarb,  and  of 
alkali  with  occasionally,  if  the  liver  be  specially  affected,  a 
little  grey  powder,  podophyllin,  or  other  cholagogue,  is  con- 
stantly of  service.  Counter-irritation  over  the  stomach  and 
liver  should  also  be  employed. 

Constipation  and  diarrhoea  demand  no  special  comment, 
only  it  is  to  be  noted  that  when  the  latter  occurs  in  waxy 
cases,  opiates  in  enemata,  or  suppositories  may  be  safely 
employed,  while  they  are,  of  course,  eminently  dangerous  in 
cirrhotic  or  inflammatory  cases. 

The  ansemia,  which  is  so  constant  a  symptom,  demands 
the  use  of  iron,  as  I  have  already  shown,  and  very  often  it 
will  be  found  that  chalybeates,  in  combination  with  bitter 
tonics,  are  of  value  also  in  the  way  of  improving  digestion. 

The  condition  of  the  heart  and  the  circulation  often  calls 
for  very  careful  management.  Frequently  iodide  of  potas- 
sium, nitro-glycerine,  and  other  nitrites  are  indicated  for  their 
action  in  the  way  of  relieving  excessive  arterial  tension ;  and, 
on  the  other  hand,  digitalis,  strophanthus,  and  caffeine,  are 
helpful  when  the  muscular  fibre  of  the  heart  threatens  to  fail, 
and  arterial  tension  is  consequently  falling.  Such  tonics  as 
nux  vomica,  quinine,  iron,  arsenic,  and  their  combinations, 
also  help  to  give  tone  to  the  weakened  muscular  fibre  of  the 
heart. 

No  complication  is  more  alarming  than  pericarditis,  for  it 
often  ushers  in  the  fatal  result,  but  in  such  cases  recovery 
may  take  place.  The  application  of  leeches  over  the  prsecor- 
dia  has  appeared  to  me  of  real  service  in  some  cases.     You 


TREATMENT    OF    COMPLICATIONS.  221 

have  lately  seen  an  instance  of  this  in  the  Paton  Ward  :  a 
patient,  who  was  suffering  from  severe  subacute  inflammation 
of  the  kidneys  with  great  dropsy,  who  was  passing  only  about 
twenty  ounces  of  urine  per  diem,  complained  of  pain  in  the 
chest.  Examination  showed  that  this  was  due  to  pericarditis, 
and  the  most  marked  to-and-fro  friction  rapidly  developed. 
Six  leeches  were  applied  over  the  prsecordia ;  no  further 
effusion  took  place  into  the  pericardium,  and  within  three 
days  the  friction  disappeared.  It  may  be  worth  while  to 
remind  you  that  the  dropsy  was  so  severe,  and  was  interfering 
to  such  an  extent  with  respiration,  that  it  was  necessary  to 
tap  the  pleura  even  while  the  pericarditis  was  going  on.  One 
hundred  and  four  ounces  of  fluid  were  withdrawn,  and  the 
heart  showed  no  sign  of  disturbance  during  the  process. 
You  will  not  often  see  so  satisfactory  a  termination  of  acute 
pericarditis  in  this  disease,  especially  when  attended  by  such 
a  complication. 

The  affections  of  the  bronchial  tubes,  and  of  the  trachea 
and  larynx,  require  little  special  notice,  excepting  in  so  far  as 
they  may  render  the  use  of  pilocarpine  hazardous,  and  may 
increase  the  tendency  to  oedema  glottidis.  You  will  remem- 
ber that  I  have  seen  tracheotomy  suddenly  rendered  neces- 
sary from  this  cause. 

For  the  relief  of  acute  and  chronic  oedema  of  lung,  counter- 
irritation  and  dry-cupping  are  among  our  best  remedies. 
Much  good  also  comes  from  the  use  of  cardiac  tonics  acting 
as  diuretics,  and  at  the  same  time  improving  the  pulmonary 
circulation.  The  ordinary  expectorant  and  antispasmodic 
remedies  must  not  be  neglected. 

For  dropsical  effusion  into  the  pleura,  or  into  the  peri- 
toneal cavity,  tapping  is  our  best  means  of  treatment.  We,  of 
course,  try  first  what  can  be  accomplished  by  means  of  diur- 
etics, but  I  have  long  been  in  the  habit  of  giving  mechanical 
relief  whenever  dropsy  is  considerable  and  refuses  to  yield  to 


222  ALBUMINURIA. 

the  simpler  methods.  In  the  case  of  the  man  to  whom  I 
have  just  referred,  you  observed  how  rapidly  diuresis  set  in 
when  once  the  pleural  fluid  had  been  removed.  His  urine 
rose  to  70,  100,  130  ounces,  and  his  anasarca  correspond- 
ingly subsided. 

The  nervous  complications  of  a  ursemic  character  have 
been  already  mentioned.  The  hemorrhagic  and  embolic 
processes  require  no  special  treatment. 

You  will  occasionally  find  yourselves  in  a  difficult  position 
when  renal  disease  is  associated  with  pregnancy.  It  is  best 
to  let  the  friends  of  the  patient  know  that  the  combination 
is  always  formidable,  and  sometimes  very  dangerous.  At  the 
same  time  it  must  be  remembered  that  a  large  proportion  of 
the  cases  pass  through  the  confinement  without  showing  any 
untoward  symptom,  and  your  duty  is  simply  to  be  watchful 
and  to  act  with  promptitude  if  serious  symptoms  manifest 
themselves.  The  delivery  should  be  brought  on  and  carried 
through  as  quickly  as  possible,  while  the  ursemic  symptoms 
should  be  treated  on  the  ordinary  principles  applicable  in 
such  conditions,  only  it  may  be  remarked  that  in  these  cases 
general  blood-letting  seems  to  be  of  service  more  frequently 
than  it  is  in  the  more  ordinary  forms. 


In  febrile  albuminuria  the  indications  appear  to  me  to  be 
mainly  to  favour  the  action  of  the  bowels  and  the  skin,  and 
to  stimulate  the  kidney  by  the  use  of  diluent  drinks. 
Perhaps  free  action  of  the  bowel  is  useful,  if  not  distinctly 
contra-indicated  ;  but  as  the  mere  albuminuria  is  generally 
unimportant  when  compared  with  other  elements  in  the 
case,  this  subject  need  not  be  dwelt  upon. 


In  albuminuria  due  to  heart  disease  the  most  strikingly 
good  effects  follow  the  use  of  appropriate  medicines.  In  the 
majority  of   cases  the    increased    backward    pressure    from 


TREATMENT    OF    FUNCTIONAL    CASES.  223 

weakness  of  the  cardiac  muscle  is  the  cause  ;  and  the  cardiac 
tonics — above  all,  digitalis  and  strophanthus,  but  also  caffeine, 
convallaria  majalis,  and  iron  with  arsenic — prove  of  service. 
In  the  rarer  cases,  where  the  albuminuria  is  due  to  embolic 
processes,  these  remedies  are  to  be  avoided  ;  the  circulation 
must  be  kept  as  quiet  as  possible.  The  discharge  is  usually 
transitory.  But,  as  with  regard  to  diet,  so  with  medicine, 
the  treatment  of  albuminuria  in  these  cases  scarcely  deserves 
mention. 

In  albuminuria  with  derangement  of  the  digestive  system, 
the  treatment  has,  of  course,  to  be  directed  to  the  digestive 
abnormalities.  In  the  hepatic  forms,  arsenic  and  chloride  of 
ammonium  have  seemed  to  me  specially  serviceable. 

If  suitable  cases  occurred,  I  should  try  gastric  sedatives 
where  I  found  that  the  ingestion  of  food  was  immediately 
followed  by  albuminuria.  A  combination  of  bismuth  with 
hydrocyanic  acid  would  deserve  the  first  trial.  If  one  found 
reason  to  suspect  defective  action  of  the  pancreatic  secretion 
it  would  be  well  to  try  the  liquor  pancreaticus  or  pancreatine, 
as  Dr.  Lauder  Brunton(108)  did  in  a  case  which  he  has  most 
interestingly  described  in  his  work  on  the  Disorders  of 
Digestion. 


The  albuminuria  attending  upon  nervous  disease  and  upon 
glycosuria  does  not  demand  special  treatment. 


Of  the  varieties  of  functional  albuminuria,  the  paroxysmal 
does  not  require  active  medication  during  the  persistence  of 
the  attack.  If  the  patient  be  kept  quiet,  the  action  of  the 
skin  favoured,  and  diluent  drinks  administered,  it  will  spon- 
taneously subside.  During  the  intervals,  such  drugs  as 
arsenic,   quinine,   iron,  and  chloride  of  ammonium,    should 


224  ALBUMINURIA. 

be  carefully  tried.  The  dietetic  albuminurias  are  really  of 
the  nature  of  idiosyncracies,  and,  beyond  the  obviously  indi- 
cated attention  to  diet,  I  have  not  found  any  treatment 
serviceable,  excepting  where  the  chloride  of  ammonium 
seemed  to  check  it  in  one  case,  and  arsenic  in  some  others. 
There,  also,  it  seemed  to  be  by  improving  the  general  condi- 
tion of  the  system  that  the  good  result  was  obtained.  The 
remarks  which  I  have  already  made  as  to  albuminuria  with 
derangement  of  the  digestive  system  find  application  here 
also.  In  the  varieties  connected  with  muscular  exercise, 
I  cannot  claim  to  have  seen  medicines  of  distinct  service. 
The  simple  persistent  albuminuria  has  also,  in  my  experi- 
ence, generally  resisted  the  action  of  drugs. 


Accidental  albuminuria  is,  of  course,  relieved  when  we 
succeed  in  checking  the  source  of  contamination.  Astrin- 
gents which  arrest  haemorrhages  are  thus  sometimes  of 
service.  The  removal  of  gravel  or  of  calculi  by  medical 
or  surgical  means  leads  often  to  the  subsidence  of  pyelitis, 
of  haemorrhage,  or  of  vesical  catarrh.  Such  remedies  as 
uva  ursi,  triticum  repens,  liquor  potassae,  hyoscyamus,  and 
copaiba,  which  diminish  inflammation  of  the  urinary  tract, 
are,  of  course,  of  great  service.  I  have  given  a  careful  trial 
to  arbutin  and  tannate  of  sodium  in  cases  of  this  kind, 
and  have  found  nothing  to  record  in  their  praise. 


INDEX 

OF 

BOOKS  AND  PAPERS  REFERRED  TO  IN  THE  LECTURES. 


References  are  numbered  according  to  the  order  in  which  they  occurred. 


1.  Hammarsten,  Ueber  das  Paraglobulin.     Pfliigcr's  Archiv,  1878. 

2.  Bence  Jones,   Animal   Chemistry,   p.  108.      Details    in   the   Philosophical 

Transactions  for  1847. 

3.  Hoppe-Seyler,  Handbuch  d.  Phys.  und  Path.  Chern.  Analyse,  4te  Aufl.,-p.  223. 

4.  George  Johnson,    Another  New  Test  for  Albumen,  Lancet,   vol.   ii.   1882, 

p.  737  ;  Pharmaceutical  Journal,  25th  October,  1884,  p.  329.  Albumen 
and  Sugar  Testing,  1884,  p.  6. 

5.  Tanret,  The  Volumetric  Estimate  of  Albumen  in  Urine.      By  Guy  Neville 

Stephen,  M.R.C.S.,  Lancet,  vol.  ii.  1882,  p.  614. 

6.  Oliver,  Bedside  Urine  Testing.     3rd  edition,  p.  121. 

7.  Pavy,  Lancet,  vol.  ii.  1882,  p.  823. 

8.  Wenz,  Zeitschr.  fur  Biologie,  vol.  xxii.  1. 

9.  Halliburton,  Journal  of  Physiology,  vol.  viii.  1887,  p.  185. 

10.  Randolph's  Test,  Lancet,  28th  June,  1884. 

11.  Oliver,  Bedside  Urine  Testing.     3rd  edition,  p.  90. 

12.  Pavy,  British  Medical  Journal,  vol.  i.  1883,  p.  308. 

13.  Oliver,  Bedside  Urine  Testing.     3rd  edition,  p.  109. 

14.  Oliver,  Bedside  Urine  Testing.     3rd  edition,  p.  133. 

15.  Esbach's  Method.      Por  full  directions  see  British  Medical  Journal,   1884. 

vol.  i.  p.  898.  The  original  account  of  this  method  was  published  in 
the  Bulletin  General  de  Therapeutique  Medicate  et  Chirurgicale,  t.  xcviii. 
p.  497. 

16.  Roberts,  On  Urinary  and  Renal  Diseases.     4th  edition,  p.  191. 

17.  Oliver,  Bedside  Urine  Testing.     3rd  edition,  p.  134. 

18.  George  Johnson,  Albuminometry  by  Esbach's  Tubes,  Lancet,  vol.  ii.  1886, 

p.  63. 

19.  Posner,     Virchow's    Archiv,    vol.     civ.    p.     1,     and    Notiz     zur     Normalen 

Albuminuric  [Orig.  Mitt.),  Ccntralblatt  fiir  die  Medicinischen  Wissen- 
schaften,  4th  June,  1887,  No.  23. 

20.  Senator,  On  Albuminuria  in   Health  and   Disease,  Neio  Sydenham  Society, 

1884,  and  Berliner  Klinische  Wochenschrift,  1885,  Nos.  15  and  16. 

21.  Kleudgen,  Archiv  f.  Psychiatric,  xi.  S.  478,  1881. 

22.  De  la  Celle  de  Chateaubourg,  These  de  Paris  sur  V Albuminuric  Physiologique. 

13th  July,  1883. 

225  q 


226  INDEX    OF    BOOKS    AND    PAPERS 

23.  Capital},  These  de  Paris  sur  V Albuminuric  Transitoire,  p.  13,  1883. 

24.  Leube,  Virchow's  Archiv.,  72,  Bd.  S.  145,  1878. 

25.  Von  Noorden,  Deutsches  Archiv  fur  Klinische  Medicin,  January,  1886. 

26.  Munn,  New  York  Medical  Record,  xv.  p.  297. 

27.  Leroux,  Revue  de  Medecine,  1883. 

28.  W.  A.  Stirling,  Lancet,  1887,  ii.  p.  1157. 

29.  George  Johnson,  Latent  Albuminuria  ;  Its  Etiology  and  Pathology,  British 

Medical  Journal,  vol.  ii.  1879,  p.  928. 

30.  Fiirbringer,  Zeitschrift  fur  Klinische  Medicin,  1880,  i.  S.  346. 

31.  Fischel,  Ueber  Puerperale  Peptonurie,  Arch,  fur  Gynceck,  Bd.  xxiv.  S.  400. 

Neue  Untersuchungen  ilber  den  Peptongehalt  der  Lochien  nebst  Bemer- 
kungen  iiber  die  Ursachen  der  Puerperalen  Peptonurie.  Arch,  fur  Gynceck, 
Bd.  26  S.  120,  1885. 

32.  Ealfe,  Clinical  Chemistry,  p.  149. 

33.  Ribbert,  Nephritis  und  Albuminuric,  1881. 

34.  Litten,  Centralblatt,  1880,  No.  9. 

35.  Nussbaum,  Pfiuger's  Archiv,  Bd.  xvii.  S.  580.     Revue  Mensuelle,  1880,  p.  257. 

36.  Stokvis,    Recherches    Experimentales    sur    les    Conditions    Pathogeniques    de 

V  Albuminuric,  1867. 

37.  Majendie,  Claude  Bernard's  Lecons  sur  les  liquides  de  I'organisme,  t.  ii.  p.  139, 

38.  Mosler,  quoted  by  Stokvis  (36). 

39.  Owen  Rees,  Guy's  Hospital  Reports,  1843,  p.  326. 

40.  Herrmann,  Virchoivs  Archiv,  vol.  xvii.  p.  451. 

41.  Westphal,  Virchoiv's  Archiv,  vol.  xviii.  p.  509. 

42.  Bartels,  Von  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,  vol.  xv. 

p.  240. 

43.  Hoppe-Seyler,  Virchow's  Archiv,  ix.  1856,  S.  245,  and  Physiologische  Chemie, 

S.  152/. 

44.  Lepine,  Fortschritte  der  Nierenpathologie,  translated  by  Havelburg,  Berlin, 

1884. 

45.  Wundt,    Ueber  den   Kochsalzgehalt   des  Hams,  Frdmann's  Journal,  t.   lix. 

p.  359. 

46.  Rosenthal,  Ueber  Albuminurie  bei  Inanition,  Wochenblatt  der  Wiener  Aerzte, 

1864,  22nd  September,  p.  365. 

47.  Estelle,  These  de  la  Faculte  de  Lyon,  1850,  and  Revue  Mensuelle,  1880. 

48.  Faveret,  These  de  la  Faculte  de  Lyon,  1882,  and  Revue  de  Midecine,  1882. 

49.  Semmola,   Revue  Mensuelle,  1880,  p.   239.      Archives  de  Physiologic,  1882, 

t.  i.  p.  59,  and  1884,  t.  i.  p.  287. 

50.  Ott  and  Collmar,   Journal  of  Physiology,  vol.  viii.  p.  218. 

51.  Ralfe,  On  some  Clinical  Relations  of  Functional  Albuminuria,  Lancet,  ii. 

1886,  p.  764. 

52.  Rosenbach,  Berliner  Klinische  Wochenschrift,  1884,  xxi.  p.  751. 

53.  Lepine,  Revue   Critique  sur  V Albuminuric  dyscrasique,  Revue  de  Medecine, 

1884,  p.  912. 

54.  Maguire,  The  Albumens  of  the  Urine,  Lancet,  vol.  i.  1886,  pp.  1062,  1106. 

55.  Grainger  Stewart,  On  the  Waxy  or  Amyloid  Degeneration  of  the  Kidney. 

Medico- Chirurgical  Transactions,  Edinburgh,  1861. 

56.  Aufrecht,  Die  diffuse  Nephritis,  1879. 

57.  Runeberg,  Deutsches  Archiv  f.  Klin.  Med.,  xxiii.  1879,  S.  41. 

58.  Herrmann,  Zeitschrift  fur  rationelle  Medicin,  1863,  xvii.  S.  1. 

59.  Von  Overbeck,  Sitzungsberichte  der  Wiener  Akademie,  xlii.  2  S.  189. 


REFERRED  TO  IN  THE  LECTURES.  227 

60.  Frangois,  Contribution  a  Vetudc  clu  rein  cardiaque,  These  de  Montpcllier,  1881, 

p.  25. 

61.  Robinson,  Medico-ckirurgical  Transactions,  London,  1843. 

62.  Posner,  Virchow's  Arckiv.,  Ed.  lxxix.  S.  341. 

63.  Heidenhain,  Hermann's  Hand-buck  dcr  Pkysiologie,  Bd.  v. 

64.  Bamberger,  Wiener  Mediciniscke  Wockensckrift,  1881,  S.  179. 

65.  Charcot,  Lecons  sur  les  conditions  Pathogeniques  de  V Albuminuric 

66.  Roy,  Virchow's  Archiv,  Bd.  92. 

67.  Grainger  Stewart,  Bright 's  Diseases.     2nd  edition,  p.  16. 

68.  Andrew  Clark,  Medical  Times  and  Gazette,  vol.  i.  1873,  p.  1. 

69.  Grainger   Stewart,   Britisk  and  Foreign   Medico-Chirurgical   Review,   1868, 

p.  201. 

70.  Rosenstein,  Die  Pathologie  und  Therapie  der  NierenkranTcheiten.     3rd  edition. 

71.  Johnson,  Lectures  on  Blight's  Disease,  London,  1873  ;  and  other  Works. 

72.  Gull  and  Sutton,  Medico-C'hirurgical  Transactions,  lv.,  28th  May,  1872. 

73.  Mahomed,  Medico-Chirurgical  Transactions,  London,  vol.  xvii.  1874. 

74.  Fiirbringer,  Virchoio's  Arckiv,  vol.  lxxi. 

75.  Dickinson,  Diseases  of   the  Kidney  and  Urinary  Derangements.      Part  ii. 

p.  500. 

76.  Ralfe,  Diseases  of  the  Kidneys,  1885. 

77.  Purdy,  Bright's  Disease,  p.  257. 

78.  Bartels,  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,  vol.  xv.  p.  625. 

79.  Wagner,  Krankheiten  des  Harnapparats  in  Handbuch  der  Speciellen  Patholo- 

gie und  Therapie,  Yon  Ziemssen,  Dritte  Auflage. 

80.  Lecorche,  Traite  des  Maladies  des  Reins,  p.  652. 

81.  Charcot,  Lecons  sur  les  Maladies  du  foic,  des   Voies  Biliairet  et  des  Reins, 

Paris,  1877,  p.  349. 

82.  Murchison,  Lectures  on  Diseases  of  the  Liver.     2nd  edition,  p.  34. 

83.  Dyce   Duckworth,  Notes  upon  some  Forms  of   Hepatic  Enlargement,  St. 

Bartholomew's  Hospital  Reports,  vol.  x. 

84.  Stevenson  Thomson,  Scarlatinal  Albuminuria  and  the  Prealbuminuric  Stage, 

Medico-Chirurgical  Transactions,  London,  vol.  lxix. 

85.  George  Middleton,  Discussion  on  Albuminuria.     Glasgcno  Medical  Journal, 

1884,  p.  115. 

86.  Warburton  Begbie,  Works,  Sydenham  Society,  1882. 

87.  Matthews  Duncan,  Medico-Chirurgical   Transactions,  London,   18S4.     2nd 

series,  vol.  xlix.  p.  273. 

88.  Englisch,  Wiener  medicinisches  Jahrbuch,  1884. 

89.  Frank,  Berliner  Klinische  Wochenschrift,  1887,  No.  38,  S.  707. 

90.  Murchison,  Diseases  of  the  Liver.     3rd  edition. 

91.  George  Harley,  Hepatic  Albuminuria,  Diseases  of  the  Liver,  p.  793. 

92.  Warburton  Begbie,  Edinburgh  Medical  Journal,  1874. 

93.  Arnold  Pollatschek,  Zeitschrift  fur  Klinische  Medicin,  Bd.  xii.  p.  379. 

94.  Christison,  On  Granular  Degeneration  of  the  Kidneys,  1839,  p.  36. 

95.  Jaccoud,    Nouv.   Diet,   de   Med.,   i.     Paris,  1864.     Quoted  in   British    and 

Foreign  Medico-Chirurgical  Review,  April,  1868,  p.  325,  &c. 

96.  Moxon,  Guy's  Hospital  Reports,  1878,  vol.  xxiii.     3rd  series. 

97.  T.  Morley  Rooke,  British  Medical  Journal,  1878,  vol.  ii.  p.  596. 

98.  Burney  Yeo,  Britisk  Medical  Journal,  1878,  vol.  ii.  p.  627. 

99.  Clement  Dukes,  British  Medical  Journal,  1S78,  vol.  ii.  p.  794  ;  and  1881, 

vol.  ii.  p.  776. 


228  INDEX  OF  BOOKS  AND  PAPERS. 

100.  Mahomed,  Lancet,  1879,  vol.  i.  p.  77. 

101.  Runeberg,  Deuts'ches  Archiv  filr  Klinische  Medicin,  Bd.  xxiii.  1879. 

102.  Saundby,  British  Medical  Journal,  1879,  vol.  i.  pp.  699,  700  ;  and  1880,  vol.  i. 

pp.  841-843. 

103.  Leube,  Lancet,  1878,  vol.  i.  p.  501  ;  1881,  vol.  i.  p.  468  ;  and  Medical  Times 

and  Gazette,  9th  November,  1878,  p.  546. 

104.  Quain,  Lancet,  1879,  vol.  i.  p.  86. 

105.  Semmola,  Lancet,  1879,  vol.  ii.  p.  583. 

106.  Von  Noorden,  Deutsches  Archiv  fur  Klinische  Medicin,  Bd.  1886. 

107.  Keen,  Philadelphia  Medical  Times. 

108.  Stanley  Rendall,  Etude  sur  V Albuminuric  Alimentaire,  These  pour  le  Doctorat 

en  Medecine.     Paris,  1883. 

109.  Pavy,  On  Cyclic  Albuminuria,  British  Medical  Journal,  1885,  vol.  ii.  p.  789. 

110.  Maguire,  Medical  Chronicle,  1886. 

111.  Rosenbach,  quoted  in  London  Medical  Record,  1880,  p.  450. 

112.  John  Abercrombie,  British  Medical  Journal,  1881,  vol.  ii.  p.  522. 

113.  Oliver,  Lancet,  1885,  vol.  i. 

114.  Andrew  Clark,  Lancet,  1886,  vol.  i.  p.  108. 

115.  Campbell  Black,  Lancet,  1882,  vol.  ii.  pp.  617,  654. 

116.  Coats,  Discussion  on  Albuminuria,  Glasgow  Medical  Journal,  1884,  p.  90. 

117.  Lauder  Brunton  and  D'Arcy  Power,  St.    Bartholomew' 's   Hospital  Reports, 

xiii.  p.  283. 

118.  Dobradin,  On  the  Influence  of  Egg-white  on  the  course  of  Albuminuria  in 

Nephritis,  quoted  in  London  Medical  Record,  April,  1887,  p.  150. 

119.  Claude  Bernard,  quoted   by  Lauder  Brunton  and    D'Arcy  Power,   p.    286 

(see  117). 

120.  Noel-Paton,  Relationship  of  Urea  Formation  to  Bile  Secretion,  Journal  of 

Anatomy  and  Physiology,  October,  1885,  and  January,  1886. 

121.  Thomas  Oliver,  Relationship  of   Urea  to  certain  Diseased  Processes,  British 

Medical  Journal,  27th  November,  1886. 

122.  Dickinson,   Diseases  of    the  Kidney  and  Urinary  Derangements,  part   ii. 

pp.  348,  452,  526. 

123.  Bartels,  Von  Ziemssen's  Cyclopsedia  of  the  Practice  of  Medicine,  vol.  xv. 

pp.  296,  406,  490,  537. 

124.  Lauder  Brunton,  Pharmacology,  Therapeutics,  and  Materia  Medica,  p.  435. 

125.  Lauder  Brunton,  Disorders  of  Digestion,  pp.  208  et  seq. 

126.  Fothergill,  Practitioners'  Handbook  of  Treatment,  pp.  397,  398. 

127.  Allard    Memminger,    New    York  Medical  Journal,    31st  July,    1886 ;    and 

Edinburgh  Medical  Journal,  December,  1886. 

128.  Ringer,  Handbook  of  Therapeutics.     5th  edition,  p.  177. 

129.  Saundby,  British  Medical  Journal,  vol.  ii.  1886,  p.  1011. 


INDEX. 


Abercrombie  on  albuminuria  from  diphtheria,  153. 

Acid  albumen,  2. 

Adolescence,  albuminuria  of,  138,  139,  140. 

effect  of  diet  on,  140. 
Age  of  patient  in  diagnosis,  182. 
Ague,  126. 

Albumen,  serum,  2  ;  in  waxy  disease,  116  ;  from  ingestion  of  eggs,  197. 
acid,  2,  160. 
alkali,  2,  160. 
composition  of,  3. 
tests  for,  3  et  seq. 

comparative  delicacy  of  tests  for,  10. 
quantitative  estimation  of,  13. 
in  normal  urine,  17,  49. 

explanation  of  presence  of,  in  normal  urine,  19. 
transudation  of,  from  glomeruli,  50  ;  into  tubules,  62,  132. 
excess  of  normal  in  blood,  54. 
presence  of  abnormal  in  blood,  55,  82,  122,  130,  134;  egg-albumen,  56; 

casein,  56. 
combined  with  foreign  substances,  57. 

amount  of,  in  urine,  in  nephritis,  69,  73  ;  in  cirrhosis,  77,  79,  81,  110  ; 
in  cirrhosis  with  waxy  disease,  102  ;  in  waxy  disease,  114 ;  in 
simple  persistent  albuminuria,  167  ;  importance  of  in  diagnosis, 
178  ;  effect  of  diet  on,  203  et  seq.  ;  effect  of  medicines  on,  211 
et  seq. 
in  pyrexial  albuminuria,  129. 
absorption  of,  by  ulcerated  surfaces,  134. 
abnormal  in  urine  in  functional  albuminuria,  142. 
variety  of,  present  in  cyclic  albuminuria,  159. 
absence  of,  in  cirrhosis,  168,  178. 

in  waxy  disease,  178. 
variety  of,  in  diagnosis,  179. 
importance  of  drain  of,  185. 
amount  of,  in  ordinary  diet,  185. 
in  blood,  185. 

229 


230  INDEX. 

Albumen — continued. 

formula  for  calculating  loss  of,  186. 

egg-albumen,  injection  and  ingestion  of,  in  relation  to  albuminuria, 
194. 
Albuminuria,  among  tbe  presumably  healthy,  17  ;  conclusions  as  to,  30 ; 
explanation  of,  175. 

among  soldiers,  20. 

among  civil  population,  20. 

among  children,  21. 

among  old  men,  21. 

among  infants,  22. 

among  persons  proposing  for  life  insurance,  22. 

affected  by  breakfast,  24. 

affected  by  muscular  exercise,  25. 

affected  by  marching,  25. 

affected  by  fatigue  duty,  26. 

affected  by  playing  football,  27. 

from  playing  wind  instruments,  29,  176. 

from  cold  bathing,  29,  148,  176. 

from  mental  excitement,  30,  176. 

among  the  sick,  32  ;  conclusions  as  to,  45. 

categories  of  cases  examined  for,  35. 

febrile,  36  et  seq.,  123 ;  cause  of,  128  ;  prognosis  in,  181  ;  diet  in,  207  ; 
treatment  of,  222. 

vascular,  36  et  seq.,  131  ;  cause  of,  132  ;  treatment  and  prognosis  in, 
189,  222. 

alimentary,  36  et  seq.,  133 ;   prognosis  in,  189 ;    diet  in,  208 ;  treat- 
ment of,  223. 

nervous,  36  et  seq.,  65,  135. 

with  glycosuria,  36  et  seq.,  137.     See  Glycosuria. 

functional,  36  et  seq.,  138  et  seq. ;  facies  of,  182.     See  Functional,  and 
synonyms. 

accidental,  37  et  seq.,  169  ;  prognosis  in,  191  ;  diet  in,  210  ;  treatment 
of,  224. 

probably  accidental,  37  et  seq. 

simple  persistent,  40,  139,  164  ;  diet  in,  209  ;  treatment  of,  224. 

in  scarlet  fever,  44,  125. 

in  whooping-cough,  44. 

in  alcoholism,  44,  136. 

theory  of,  49,  58,  60,  66,  67. 

from  changes  in  the  blood,  51. 

from  wateriness  of  blood,  51. 

from  inspissation  of  blood,  52. 

in  cholera,  52. 

from  excess  of  salts  in  the  blood,  53. 


INDEX.  •  231 

Albuminuria — continued. 
from  excess  of  urea,  53. 

from  excess  of  normal  albumens  in  blood,  54. 
from  presence  of  abnormal  albumens  in  blood,  55  ;  egg-albumen,  56  ; 

casein,  56. 
relation  to  hemoglobinuria,  56,  143. 
from  albuminous  compounds  with  foreign  substances,  57. 
from  globulin,  57. 

from  altered  states  of  filtering  apparatus,  58. 
from  abnormal  vascular  tension  and  altered  circulation,  60. 
from  venous  stasis,  62. 
from  increased  arterial  pressure,  63. 
from  influence  of  nervous  system,  64. 

from  morbid  action  of  renal  epithelium  and  other  structures,  66. 
from  inflammation  of  the  kidneys,  68  ;  cause  of,  in  nephritis,  75. 
from  cirrhosis  of  the  kidneys,  76  ;  cause  of,  in  cirrhosis,  82. 
persistent,  71. 

from  waxy  kidney,  1 14  ;  cause  of,  in  waxy  disease,  122. 
in  typhus  and  typhoid,  126. 
initial  and  late  varieties  of,  in  scarlatina,  125. 
in  malarial  poisoning,  126. 
with  various  zymotic  diseases,  127. 
Avith  parametritis,  127. 
in  strangulated  hernia,  128. 
forms  of  alimentary  derangement  with,  133. 
from  ingestion  of  food,  133,  145,  147  ;  explanation  of,  151. 
»  with  diarrhoea,  134. 
with  hepatic  derangements,  134  ;  cause  of,  135. 
from  ascites,  134. 
intermittent,  138,  139  ;  peptones  in,  160  ;  arsenic  and  pancreatine  in 

treatment  of,  212. 
dietetic,  138,  144  ;  explanation  of,  150  ;  effect  of  exercise  on,  176. 
cyclical,  138,  141. 

of  adolescence,  138,  139,  140  ;  diet  in,  140. 
paroxysmal,  139,  142  ;  explanation  of,  144  ;  treatment  of,  223. 
from  muscular  exertion,  139,  147,  152  ;  cause  of,  1'64,  175  ;  diet  in, 

208. 
remittent,  139. 
in  families,  140. 
authors  on  functional,  141. 
from  cheese,  145. 
from  pastry,  145. 
from  eggs,  145,  155. 
influenced  by  season  of  year,  147,  178. 
from  diphtheria,  152. 


232  INDEX. 

Albuminuria — continued. 

effect  of  rest  in  bed  on,  154. 

milk  diet  in,  155. 

from  catamenia,  169. 

from  gonorrhoea,  170. 

from  prostatic  disease,  170. 

from  seminal  fluid,  170. 

from  diseases  of  bladder,  171. 

from  renal  calculus,  171. 

from  suppuration  in  kidney,  &c,  173. 

of  pregnancy,  174  ;  prognosis  in,  187  ;  treatment  of,  222. 

from  hindrance  to  outflow  of  urine,  174. 

diagnosis  in,  178  et  seq. 

importance  of  drain  of  albumen  in,  185. 

on  diet  in,  193. 

egg-albumen  in,  194. 

from  ingestion  of  eggs,  194  et  seq.  ;  explanation  of,  197. 

from  cheese,  198. 

from  walnuts,  199. 

use  of  alcohol  in,  210. 

effect  of  medicines  in,  211  et  seq.     See  various  drugs. 
Albuminuric  retinitis,  98,  184. 
Albumoses,  2. 
Alcohol,  as  cause  of  cirrhosis,  78. 

use  of,  in  albuminuria,  210. 
Alcoholism,  albuminuria  in,  44. 
Alimentary  system  in  diagnosis,  182. 
Alkali  albumen,  2. 
Amblyopia  in  cirrhosis,  96,  184. 

of  central  origin,  112. 
Ammonium  chloride  in  dietetic  albuminuria,  146,  212,  223. 
Ammonium  sulphate  as  a  test  for  proteids,  8. 
Amyloid  material,  3. 
Ansemia  in  cirrhosis,  86. 

in  nephritis,  87. 

in  waxy  kidney,  87. 

treatment  of,  220. 
Anasarca,  92,  184. 
Aphasia,  107,  108  et  seq. 
Apoplexy,  albuminuria  after,  65. 

hsemorrhagic,  in  cirrhosis,  &c,  106,  113. 
Arbutin  in  albuminuria,  212,  224. 

in  nephritis,  216. 
Arsenic  in  albuminuria,  212,  215,  220,  223. 
Arterial  sclerosis,  90. 


INDEX.  233 

Arterial  tension,  increased,  in  cirrhosis,  90. 

prealbuminuric,  91. 

as  a  cause  of  albuminuria  in  fever,  130. 

in  diagnosis,  183. 

relief  of,  220. 
Arterio-capillary  fibrosis,  91. 
Atrophy,  acute  renal,  66. 
Aufrecht  on  urinary  stasis,  60. 
Auscultatory  changes  in  heart,  in  diagnosis,  183. 

Bartels,  on  albuminuria  in  cholera,  53. 

on  diet  in  Bright's  disease,  201. 

on  iodide  of  potassium  in  cirrhosis,  218. 

on  polyuria  in  waxy  disease,  118. 
Bathing,  albuminuria  from,  29. 
Bed,  rest  in,  as  influencing  albuminuria,  154. 
Begbie,  Warburton,  on  albuminuria  in  exophthalmic  goitre,  136. 

on  febrile  albuminuria,  127. 
Belladonna,  in  nephritis,  216,  217. 

in  cirrhosis,  218. 

in  waxy  disease,  219. 
Bernard,  Claude,  on  eggs  in  albuminuria,  195. 
Bile-salts,  161  ;  tests  for,  162. 
Biuret  reaction,  9. 

Black,  Campbell,  on  prostatic  casts,  170,  181. 
Bladder,  catarrh  of,  in  disease  of  spinal  cord,  137. 

diseases  of,  as  a  cause  of  albuminuria,  171. 
Blood,  changes  in,  as  a  cause  of  albuminuria,  51  et  seq.  ;  of  paroxysmal 

albuminuria,  144;  of  dietetic  albuminuria,  150. 
Breakfast,  effect  of,  on  albuminuria  in  soldiers,  23  ;  in  old  men,  23  ;  in 

children,  24. 
Bright's  disease,  35,  38,  39,  41,  42,  43,  68. 

inflammatory.     See  Nephritis. 

infective  form  of,  69.     See  Nephritis. 

cirrhotic.    See  Cirrhosis  of  kidneys. 

waxy.     See  Waxy  kidney. 

paralysis  in,  106. 

diagnosis  from  functional  cases,  144,  148,  150,  156  et  seq.,  178. 

prognosis  in,  187. 

diet  in,  200. 

treatment  of,  214  et  seq. 
Brine,  acidulated,  as  a  test  for  albumen,  5. 
Broadbent  on  mercury  in  albuminuria,  213. 
Bronchitis,  in  cirrhosis,  93. 

uragmic,  95. 


234  INDEX. 

Bronchitis — continued. 

in  nephritis,  95. 

treatment  of,  221. 
Brunton,  Lauder,  on  eggs  in  albuminuria,  195. 

on  digitalis,  211. 

on  tannin  and  tannate  of  sodium,  212. 

on  pancreatine,  223. 

Calculus,  renal,  as  a  cause  of  albuminuria,  171 ;  clinical  features  of,  171, 

172. 
Capitan  on  albuminuria  among  soldiers,  18. 

on  functional  albuminuria,  141. 
Cardiac  hypertrophy.     See  Hypertrophy  of  heart. 
Casein  in  blood,  56. 
Casts  of  renal  tubules— 

in  acute  nephritis,  69. 

in  chronic  nephritis,  73. 

in  cirrhosis,  77,  79,  110. 

in  cirrhosis  with  waxy  disease,  102. 

in  febrile  albuminuria,  126. 

in  malarial  poisoning,  127. 

in  strangulated  hernia,  128. 

in  pyrexial  albuminuria,  129. 

in  circulatory  disease,  131. 

in  hepatic  albuminuria,  135. 

in  paroxysmal  albuminuria,  142. 

in  albuminuria  from  exertion,  156. 

in  cyclic  albuminuria,  163. 

diagnostic  importance  of,  181. 
Casts,  prostatic,  170,  181. 
Catamenia,  urine  during,  1 69. 
Categories  of  cases  examined  for  albuminuria,  35. 
Cerebral  haemorrhage.     See  Haemorrhage. 
Changes  in  the  blood  as  a  cause  of  albuminuria,  51. 
Charcot  on  waxy  disease,  119. 

Chateaubourg  on  albumen  in  urines  of  healthy  people,  18. 
Cheese  as  a  cause  of  albuminuria,  198. 
Children,  albuminuria  among,  21. 
Cholera,  albuminuria  in,  52. 
Christison  on  temporary  albuminuria,  139. 

on  cheese  as  a  cause  of  albuminuria,  198. 
Circulatory  system,  in  diagnosis,  183. 
Cirrhosis  of  kidneys,  facies  of,  76. 

characters  of  urine  in,  77. 

age  of  patients,  77. 


INDEX.  235 


Cirrhosis  of  kidneys — continued. 
heredity  in,  77. 
causes  of,  78. 
headache  in,  78. 
clinical  features  of,  79. 
amount  of  urea  in,  79,  81,  110,  181. 
eye  changes  in,  80. 
pathological  anatomy  of,  80. 
hypertrophy  of  heart  in,  80,  88. 
early  stage  of,  81. 
cause  of  albuminuria  in,  82. 
complications  of,  84. 
gastric  derangement  in,  84. 
intestinal  derangement  in,  85. 
hepatic  disease  in,  85. 
anaemia  in,  86. 
haemorrhages  in,  86. 
failure  of  heart  in,  88. 
increased  arterial  tension  in,  90,  183. 
arterial  sclerosis  in,  90. 
dyspnoea  in,  92  et  seq. 
pulmonary  congestion  in,  93. 
pulmonary  oedema  in,  93. 
bronchitis  in,  93. 
oedema  of  glottis  in,  94. 
pneumonia  in,  94. 
pulmonary  apoplexy  in,  94. 
pleurisy  in,  94. 
uraemic  dyspnoea  in,  94. 
changes  in  skin  in,  95,  184. 
affections  of  nervous  system  in,  96. 
headache  in,  96. 
amblyopia  in,  96. 
albuminuric  retinitis  in,  98. 
uraemia  in,  99  et  seq. 
with  waxy  disease,  104. 
paralytic  symptoms  in,  107,  109. 
advanced,  112. 
polyuria  in,  119,  180. 
with  cirrhosis  of  liver,  134. 
absence  of  albumen  in,  168,  178. 
prognosis  in,  188. 
diet  in,  200,  205. 
treatment  of,  218. 
Citric  acid  as  a  test  for  mucin,  6. 


236  INDEX. 

Civilians,  albuminuria  among,  20. 

Clark,  Sir  Andrew,  on  renal  inadequacy,  82. 

on  prostatic  casts,  170,  181. 
Climate  in  treatment  of  renal  disease,  219. 
Coats  on  egg-albumen,  195. 
Collmar  on  peptones,  56. 
Coma,  ursemic,  69,  99. 
Complications  of  renal  disease,  85  et  seq. 

treatment  of,  220  et  seq. 
Conclusions  as  to  albuminuria  among  the  sick,  45. 
Conjunctival  oedema,  76. 

Contracting  kidney.     See  Cirrhosis  of  kidneys. 
Convulsions,  ursemic,  69,  73,  99,  101,  102. 

treatment  of,  217. 
Crystalloids  of  blood  in  urine,  125. 
Cyclical  albuminuria,  138, 141. 

diagnosis  of,  178. 

Delicacy  of  tests  for  albumen,  10. 
Deterioration  of  nervous  system  in  cirrhosis,  96. 
Diabetes  insipidus,  114  ;  increased  blood  pressure  in,  63. 
Diagnosis,  of  functional  cases  from  Bright's  disease,  144,  148,  150,  156  et 
seq.,  178. 
indications  for,  given  by  character  of  albuminuria,  178. 
quantity  of  albumen,  1 79. 
variety  of  albumen,  179. 
quantity  of  urine,  180. 
specific  gravity  and  amount  of  urea,  180. 
tube  casts,  181. 

occurrence  of  phosphates,  oxalates,  and  urates,  181. 
age  of  patient,  182. 
alimentary  system,  182. 
hsemopoietic  system,  183. 
circulatory  system,  183. 
respiratory  system,  184. 
integumentary  system,  184. 
nervous  system,  184. 
locomotory  system,  185. 
Diarrhcea  in  waxy  disease,  86. 
from  waxy  intestine,  122. 
albuminuria  with,  134. 
treatment  of,  220. 
Dickinson  on  polyuria  in  waxy  disease,  118. 
on  diet  in  Bright's  disease,  200. 
on  diuresis  from  drinking  water,  215. 


INDEX.  237 

Diet,  in  albuminuria,  193. 

eggs,  184  ;  cheese,  198  ;  walnuts,  199. 

in  various  forms  of  Bright's  disease,  200,  201. 

employed  in  experiments,  202. 

experiments  on,  in  Bright's  disease,  203. 

in  febrile  albuminuria,  207. 

in  alimentary  albuminuria,  208. 

in  functional  albuminuria,  208. 

in  simple  persistent  albuminuria,  209. 

in  accidental  albuminuria,  210. 
Dietetic  albuminuria,  138,  144. 

explanation  of,  150  ;  effect  of  exercise  on,  176  ;  treatment  of,  224. 
Digitalis,  effect  of,  on  albuminuria,  64,  213,  220,  222. 

in  cardiac  disease,  132. 

in  nephritis,  215. 

in  cirrhosis,  218. 
Dilution  process,  Eoberts's,  14. 
Dilution  with  water  as  a  test  for  serum-globulin,  8. 
Diphtheria  as  a  cause  of  albuminuria,  152. 
Diuresis,  effect  of,  on  inflamed  kidney,  214. 
Diuretics  in  albuminuria,  221. 

in  nephritis,  215,  218. 
Diurnal  phenomena,  141. 
Diurnal  variation  in  bile-salts  in  urine,  161. 
Dobradin  on  eggs  in  albuminuria,  195. 
Douche,  cold,  in  albuminuria,  148. 
Dropsy  in  renal  disease,  95. 

in  diagnosis,  182. 

treatment  of,  218,  221. 
Dryness  of  skin  in  renal  disease,  95. 
Duckworth  on  recovery  from  waxy  disease,  120. 
Dukes  on  albuminuria  of  adolescence,  140,  167. 
Duncan,  Matthews,  on  albuminuria  with  parametritis,  127. 
Dyspnoea  with  hypertrophy  and  failure  of  heart,  89. 

in  renal  disease,  92. 

from  pleural  effusion,  92. 

from  oedema  of  lung,  93. 

from  oedema  of  glottis,  94. 

from  other  pulmonary  changes,  94. 

urpemic,  94,  98  ;  from  urremic  irritation  of  bronchi,  95. 

Early  cirrhosis,  case  of,  81. 
Egg-albumen  in  blood,  56. 

Eggs,  ingestion  of,  as  a  cause  of  albuminuria,  194  ;    explanation  of,  197 
experiments  with,  196,  209. 


238  INDEX. 

Embolism,  cerebral,  106,  108,  112. 
Endocarditis  in  cirrhosis,  89. 

in  nephritis,  92. 
Englisch  on  albuminuria  with  hernia,  128. 
Epilepsy,  albuminuria  in,  65. 
Epistaxis  in  cirrhosis,  86,  110. 

Epithelium,  renal,  albuminuria  from  changes  in,  66. 
Ergot,  in  nephritis,  216. 

in  cirrhosis,  218. 

in  waxy  disease,  219. 
Esbach's  method,  14. 
Estelle,  experiments  of,  54. 

Exercise,  muscular,  as  affecting  albuminuria,  25. 
Experiments  to  increase  pressure  in  aorta  and  renal  arteries,  63. 
Experiments  in  albuminuria  from  muscular  exertion,  154,  158. 
Experiments  with  ingestion  of  eggs,  196. 
Eye  changes  in  cirrhosis,  79,  98,  111,  184. 

in  albuminuria  of  pregnancy,  98. 

in  nephritis,  98. 

in  waxy  disease,  98. 

Facial  paralysis,  108. 

Failure  of  heart,  in  cirrhosis,  88. 

treatment  of,  220. 
Fatigue-duty,  effect  of,  on  albuminuria,  26. 
Faveret,  experiments  of,  54. 
Fehling's  solution,  as  a  test  for  peptones,  9. 
Ferrocyanide  of  potassium  as  a  test  for  albumen,  8. 
Fever  with  albuminuria,  prognosis  in,  189. 
Fibrin,  3  ;  test  for,  9. 
Filtering  apparatus,  alterations  in,  58. 
Filtration  experiments,  61. 
Fischel  on  puerperal  peptonuria,  47. 
Food,  ingestion  of,  as  a  cause  of  albuminuria,  25,  133,  145,  147,  194,  200. 

explanation  of,  151. 
Football,  effect  of,  on  albuminuria,  27. 
Formula  for  calculating  loss  of  albumen,  186. 
Fothergill  on  medicines  in  albuminuria,  212. 
Fractional  method,  Oliver's,  13. 
Francois  on  constriction  of  renal  artery,  61. 
Frank  on  albuminuria  with  hernia,  128. 
Fuchsin,  in  albuminuria,  212,  213. 

in  nephritis,  216,  217. 

in  cirrhosis,  218. 

in  waxy  disease,  219. 


INDEX.  239 

Functional  albuminuria,  36  et  seq.,  138  et  seq. 

diagnosis  of,  178. 

facies  of,  182. 

prognosis  in,  190. 

diet  in,  208  ;  treatment,  223. 
Fiirbringer  on  albuminuria  from  mental  excitement,  30. 

on  functional  albuminuria,  141. 

Gastric  derangement,  in  cirrhosis,  84. 

in  nephritis,  85. 

in  waxy  kidney,  86. 

treatment  of,  220. 
Globulin  in  functional  albuminuria,  in  purpura,  &c,  57. 

in  waxy  disease,  116. 
Globuloses,  2. 
Glomerulo-nephritis,  59. 
Glottis,  oedema  of,  94,  221. 
Glycosuria,  with  albuminuria,  36  et  seq.,  137,  141,  153,  164,  180,  190. 

prognosis  in,  190  ;  treatment  of,  223. 
Goitre,  exophthalmic,  albuminuria  in,  136.     Dr.  Begbie's  case,  136. 
Gonorrhoea,  170. 

Gouty  kidney.     See  Cirrhosis  of  kidney. 
Granular  kidney.     See  Cirrhosis  of  kidney. 
Gull  on  albuminuria,  140. 
Gull  and  Sutton,  on  arterio-capillary  fibrosis,  91. 

Hsematuria,  in  nephritis,  69. 

in  cirrhosis,  86. 

in  scarlatina,  125. 

in  fever,  129. 

from  prostatic  enlargement,  170. 

in  suppurative  nephritis,  173. 

from  use  of  medicines,  212. 
Haemoglobin,  3  ;  test  for,  9. 
Haernoglobinuria  in  relation  to  albuminuria,  57. 

in  cirrhosis,  87. 

paroxysmal,  142. 
Hsemopoietic  system,  in  diagnosis,  183. 
Haemorrhage,  in  fundus  oculi,  80. 

cerebral,  106. 

into  pons,  106. 

into  internal  capsule,  107,  109. 

into  occipital  lobes,  111. 

general  considerations  in  regard  to  cerebral,  113. 
Haemorrhages,  in  cirrhosis,  86. 

in  nephritis,  87. 


240  INDEX. 

Hammarsten  on  serum-albumen,  2. 

Harley  on  albuminuria  in  hepatic  disease,  134. 

Hay's  test  for  bile-salts,  163. 

Headache  in  cirrhosis,  78,  96. 

causes  of,  97. 

treatment  of,  in  cirrhosis,  218. 
Healthy,  albuminuria  among  the  presumably,  17. 
Heart-disease,  albuminuria  in,  132. 
Heat  as  a  test  for  albumen,  4. 
Hemiplegia,  106,  108,  110. 
Hepatic  complications,  in  cirrhosis,  85. 

in  nephritis,  86. 

in  waxy  kidney,  86. 

treatment  of,  220. 
Hernia,  strangulated,  albuminuria  in,  128. 
Herrmann,  experiments  of,  52. 

on  constriction  of  renal  artery,  61. 
Hoppe-Seyler,  transudation  experiments  of,  53. 
Hypertrophy  of  heart,  in  chronic  nephritis,  74,  91. 

in  cirrhosis,  80,  88. 

in  waxy  kidney,  92. 

explanation  of  dyspnoea  in,  89. 
Hysteria,  albuminuria  in,  65. 

Inadequacy,  renal,  82. 

Increased  vascular  tension  in  kidney,  62. 

Increased  arterial  pressure,  63. 

from  muscular  exertion,  64. 

from  fever,  64. 
Infants,  albuminuria  among,  22. 
Inflammation  of  the  kidney.     See  Nephritis. 
Inspissation  of  blood,  52. 
Integumentary  system  in  diagnosis,  184. 

Intermittent  albuminuria,  138,  139,  178  ;  arsenic  and  pancreatine  in,  212. 
Intestine,  waxy  disease  of,  122. 
Iron,  in  albuminuria,  212,  213,  220,  223. 

in  nephritis,  215,  216. 

in  cirrhosis,  218. 

in  waxy  disease,  219. 
Irritation  of  vasomotor  nerves,  65. 
Itching  in  renal  disease,  95. 

Jaccoud  on  persistent  albuminuria,  139. 
Johnson  on  quantitative  estimation  of  albumen,  16. 
on  albuminuria  from  bathing,  29. 


INDEX.  241 

Johnson  on  functional  albuminuria,  141. 

on  prognosis  in  functional  albuminuria,  168. 
Jones,  Bence,  on  propeptone  in  osteomalacia,  2. 
Juniper,  oil  of,  as  diuretic,  72. 

Keen  on  functional  albuminuria,  141. 
Kidney,  inflammation  of.     See  Nephritis. 

cirrhosis  of.     See  Cirrhosis. 

waxy  disease  of.     See  Waxy  kidney. 

pathological  anatomy  of.     See  Pathological  anatomy. 

morbid  alterations  in,  58,  66. 

influence  of  nervous  system  on,  64. 

irritation  of,  55,   58  ;  by  morbid    hepatic   products,   134 ;   by  blood 
changes,  144. 

suppuration  in,  173. 

haemorrhage  from,  173. 

surgical,  191. 
Kleudgen  on  albumen  in  normal  urine,  18. 

Lardacein,  3. 

Lead  in  albuminuria,  212,  213. 

Lead  poisoning  as  cause  of  cirrhosis,  78. 

Lecorche  on  waxy  disease,  118. 

Lepine,  injection  experiments  of,  53. 

on  albumen  combinations,  57. 
Leroux  on  albuminuria  among  children,  18. 
Leube  on  albuminuria  among  soldiers,  18. 

on  functional  albuminuria,  141. 
Ligature  of  renal  veins,  62,  132. 
Litten  on  transudation  of  albumen,  50. 

on  diminution  of  tension,  61. 
Liver,  albuminuria  in  disease  of,  134. 
Locomotory  system  in  diagnosis,  185. 
Luclwig  on  ligature  of  renal  veins,  132. 

Magnesium  sulphate  as  a  test  for  serum-globulin,  8. 
Magendie  on  dilution  of  blood,  51. 
Maguire  on  globulin,  57. 

on  functional  albuminuria,  141. 

on  forms  of  albumen  in  different  diseases,  159. 

on  albumens  of  the  urine,  195. 
Mahomed  on  functional  albuminuria,  141. 

on  prealbuminuric  rise  of  arterial  tension,  91. 
Malarious  fever  in  relation  to  albuminuria,  126. 
Malpighian  tufts,  49,  50,  53,  58,  59,  60,  62,  63,  64. 


242  INDEX. 

Marching,  effect  of,  on  albuminuria,  25. 
Medicines  causing  albuminuria,  211. 

diminishing  albuminuria,  212. 
Memminger  on  chloride  of  sodium  in  albuminuria,  213. 
Mental  excitement  as  a  cause  of  albuminuria,  30. 
Mercury  in  albuminuria,  212,  213. 
Metaphosphoric  acid  as  a  test  for  albumen,  5. 
Methsemoglobin,  test  for,  9. 

Middleton  on  albuminuria  in  typhus  and  typhoid  fevers,  125. 
Mosler  on  dilution  of  blood,  51. 
Moxon  on  chronic  intermittent  albuminuria,  139. 
Mucin,  3  ;  tests  for,  6  ;  increase  of,  after  ingestion  of  food,  175. 
Munn  on  albuminuria  in  healthy  people,  18. 
Murchison  on  albuminuria  in  hepatic  disease,  134. 

on  waxy  disease,  119. 
Muscular  exertion,  albuminuria  from,  139,  147,  152  ;  cause  of,  164,  175 
diet  in,  208  ;  treatment  of,  224. 

Nephritis,  post  scarlatinal,  69,  71  ;  pathological  anatomy  of,  69. 

clinical  features  of,  70  ;  non-infective  forms,  72  ;  chronic,  73. 

chronic,  pathological  anatomy  of,  74. 

complications  of,  85  et  seq. 

gastro-intestinal  derangements  in  85. 

anaemia  in,  87. 

hypertrophy  of  heart  in,  74,  91. 

valvular  disease  of  heart  in,  92. 

pericarditis  in,  74,  92. 

pleural  effusion  in,  95. 

other  pulmonary  changes  in,  95. 

eye  symptoms  in,  98. 

uraemia  in,  69  et  seq.,  105. 

paralytic  symptoms  in,  106,  109. 

superadded  to  waxy  disease,  120. 

cause  of  albuminuria  in,  67,  75. 

prealbuminuric  stage  in,  125. 

cause  of,  in  fever,  129. 

amount  of  urea  in,  72,  181. 

increased  arterial  tension  in,  183. 

prognosis  in  187. 

diet  in,  200,  203. 

treatment  of,  214. 
Nervous  system,  influence  of,  on  the  kidney,  64. 

in  diagnosis,  184. 
Nitric  acid  as  a  test  for  albumen,  5. 
Nitro-glycerine,  in  albuminuria,  213,  220. 


INDEX.  243 

Nitroglycerine — continued. 

in  cirrhosis,  218. 

in  waxy  diseases,  219. 
Nocturnal  micturition  in  cirrhosis,  79,  109. 
Noel-Paton  on  urea  formation,  197. 
Nussbaum  on  transudation  of  albumen,  50. 

(Edema  of  lungs,  in  cirrhosis,  93  ;  in  nephritis,  95  ;  treatment  of,  221. 

of  glottis,  94. 
Old  men,  albuminuria  among,  21. 
Oliver  on  bile-salts,  161,  162. 

on  peptones  in  intermittent  albuminuria,  160. 
Oliver's  fractional  method,  13. 

percentage  method,  15. 

test-papers,  12. 
Oliver,  Thomas,  on  urea  formation,  197. 
Optic  disc,  atrophy  of,  79. 

hyperemia  of,  112. 
Osteomalacia,  propeptone  in,  2. 
Ott  on  peptones,  56. 

Overbeck,  Von,  on  constriction  of  renal  artery,  61. 
Oxalates  in  urine,  135,  141,  142,  148,  153,  160,  181. 
Oxaluria,  161,  164. 

Paraglobulin,  2. 

in  cyclic  albuminuria,  159. 
Paralysis  in  Bright's  disease,  106  ;  causes  of,  106. 

diagnosis  from  ursemia,  106. 

transient,  107. 

facial,  106,  107. 

of  arm,  107. 

in  different  forms  of  Bright's  disease,  109. 

repeated,  109  et  seq. 
Paralysis  of  vasomotor  nerves,  65. 
Parametritis,  albuminuria  with,  127. 
Paroxysmal  albuminuria,  139,  142. 

relation  to  hsemoglobinuria,  142. 

explanation  of,  144. 

treatment  of,  223. 
Pathological  anatomy  of  acute  nephritis,  69. 

chronic  nephritis,  74. 

cirrhosis  of  kidneys,  80,  112. 

cirrhosis  with  waxy  disease,  104. 

waxy  disease,  120,  121. 

febrile  albuminuria,  128. 


244  INDEX. 

Pavy's  test-pellets,  12. 

Pavy  on  cyclic  albuminuria,  141. 

Peptone,  2  ;  tests  for,  9. 

Peptones  in  urine  of  presumably  healthy,  30. 

cause  of,  in  urine,  56. 

in  waxy  disease,  115. 

in  dietetic  albuminuria,  151. 

in  diagnosis,  179. 
Peptonuria,  occurrence  of,  among  the  sick,  46. 

in  puerperal  cases,  47. 

in  gastric  carcinoma,  134. 
Percentage  method,  Oliver's,  15. 
Percentage  of  patients  showing  albuminuria,  34. 
Pericarditis,  in  chronic  nephritis,  74,  92. 

in  cirrhosis,  90. 

treatment  of,  220. 
Perimetritis,  127. 
Perinephric  abscess,  174. 
Peritonitis,  pelvic,  128. 
Phosphates  in  urine,  141,  153,  160,  181. 
Phosphatic  diathesis,  141. 
Phosphaturia,  164. 
Phosphorus  poisoning,  66. 
Picric  acid  as  a  test  for  albumen,  5. 

most  delicate  test  for  albumen,  12. 
Pilocarpine,  in  albuminuria,  213. 

in  uraemia,  217. 

contra-indications  to  use  of,  221. 
Pleural  effusion  in  cirrhosis,  92. 

in  nephritis,  95 

treatment  of,  221. 
Pleurisy  in  cirrhosis,  94. 

in  nephritis,  95. 
Pneumonia  in  cirrhosis,  94. 

in  nephritis,  95. 
Pollatschek  on  albuminuria  with  glycosuria,  137. 
Polydipsia,  119. 
Polyuria  in  waxy  disease,  114,  117,  180. 

in  cirrhosis,  119,  180. 

statements  of  authors  in  regard  to,  in  waxy  disease,  118. 
Pons,  haemorrhage  into,  106. 
Posner  on  albumen  in  normal  mine,  17. 

on  transudation  of  albumen,  50. 
Potassio-mercuric  iodide  as  a  test  for  albumen,  8. 
Potassium  ferrocyanide  as  a  test  for  albumen,  8. 


INDEX.  245 

Potassium  salts,  in  albuminuria,  212,  213. 

in  nephritis,  215,  217. 

in  cirrhosis,  218. 
Power  on  eggs  in  albuminuria,  195. 
Prealbuminuric  increase  of  arterial  tension,  91. 
Prealbuminuric  stage  in  nephritis,  125. 
Pregnancy,  albuminuric  retinitis  in,  98. 

albuminuria  in,  174. 

treatment  of,  222. 

prognosis  in,  187. 
Private  patients,  albuminuria  among,  39. 
Prognosis  in  functional  albuminurias,  167,  190. 

in  Bright's  disease,  187. 

in  nephritis,  187. 

in  nephritis  with  pregnancy,  187. 

in  cirrhosis,  188. 

in  waxy  disease,  189. 

in  fevers  with  albuminuria,  189. 

in  albuminuria  in  circulatory  disease,  189  ;  in  alimentary  disease,  189  ; 
in  nervous  disease,  190  ;  in  glycosuria,  190  ;  due  to  accidental 
causes,  191  ;  in  blood  diseases,  191. 
Propeptone,  2. 

in  dietetic  albuminuria,  151. 
Prostate,  disease  of,  as  a  cause  of  abuminuria,  170. 

polyuria  in,  180. 
Prostatic  casts,  170,  181. 
Proteids  in  urine,  2. 
Pulmonary  apoplexy  in  cirrhosis,  94. 
Purdy  on  polyuria  in  waxy  disease,  118. 
Purgatives,  effect  of,  on  albuminuria,  212,  213,  216,  217. 
Pus  in  urine,  170,  172,  173, 
Pyelitis,  171,  173. 
Pyrexia,  as  a  cause  of  albuminuria,  129. 

Quain  on  functional  albuminuria,  141. 
Quantitative  estimation  of  albumen,  13. 

Ralfe  on  polyuria  in  waxy  disease,  118. 

on  excess  of  urea  with  albuminuria,  167. 

on  formation  of  urea,  197. 
Randolph's  test  for  peptones,  9. 
Raynaud's  disease,  184. 
Rectum,  injection  of  egg-albumen  into,  194. 
Rees  on  dilution  of  blood,  51. 


246  INDEX. 

Remittent  albuminuria,  139. 

Eenal  atrophy,  acute,  66. 

Eenal  epithelium,  albuminuria  from  changes  in,  66. 

Kendall  on  functional  albuminuria,  141. 

Retinitis,  albuminuric,  in  cirrhosis,  98,  184. 

Ribbert  on  glomerulo-nephritis,  59. 

on  tannin  and  tannate  of  sodium,  212. 

on  transudation  of  albumen,  50. 
Ringer  on  lead  in  albuminuria,  213. 
Roberts's  dilution  process,  14. 
Roberts  on  polyuria  in  waxy  disease,  118. 

on  effect  of  drugs  on  albuminuria,  214. 
Robinson  on  venous  stasis,  62. 
Rooke  on  effect  of  rest  in  albuminuria,  140. 
Rosenbach  on  paroxysmal  albuminuria,  57. 

on  albuminuria  and  hemoglobinuria,  143. 
Rosenstein  on  polyuria  in  waxy  disease,  118. 

on  the  effect  of  drugs  on  albuminuria,  214 
Rosenthal  on  saltless  diet,  54. 
Roy  on  nerve  structures  in  the  kidney,  65. 
Runeberg  on  altered  vascular  tension,  61. 

on  functional  albuminuria,  141. 

Salts,  excess  of,  as  cause  of  albuminuria,  53. 

deficiency  of,  54. 

influence  on  circulation  of,  151. 
Saundby  on  functional  albuminuria,  141. 

on  drugs  in  albuminuria,  213. 
Scarlet  fever,  albuminuria  in,  44,  125. 
Season,  influence  of,  on  albuminuria,  147,  149. 
Seminal  fluid,  as  cause  of  albuminuria,  170. 
Semmola  on  abnormal  albumens  in  blood,  55. 

on  functional  albuminuria,  141. 
Senator  on  albumen  in  normal  urine,  17. 

on  diminution  of  tension,  61. 

on  ligature  of  renal  veins,  62,  132. 

on  globulin  in  waxy  disease,  116. 

on  pyrexial  albuminuria,  129. 

on  excretion  of  egg-albumen,  194. 

on  iodide  of  potassium  in  albuminuria,  213. 
Serum-albumen,  2.     See  Albumen. 
Serum-globulin,  2  ;  tests  for,  8. 
Sight,  affections  of,  in  cirrhosis,  97  et  seq.,  184. 
Simple  persistent  albuminuria,  164. 
Slowing  of  circulation  in  kidney,  62. 


INDEX.  247 

Sodium,  chloride  of,  54. 

tannate  of,  in  albuminuria,  212,  213  ;  in  nephritis,  216  ;  in  accidental 
albuminuria,  224. 
Soldiers,  albuminuria  among,  20. 
Specific  gravity  of  urine  in  diagnosis,  180. 
Stevens,  on  bile-salts,  161,  162. 
Stewart,  Grainger,  on  waxy  kidney,  58. 
Stirling  on  albuminuria  from  playing  wind  instruments,  28. 
Stokvis,  injection  experiments  of,  51,  52,  55. 

on  intravenous  injection  of  egg-albumen,  194. 
Strychnia,  poisoning  by,  as  a  cause  of  albuminuria,  211. 
Sugar.     See  Glycosuria. 
Sulphate  of  ammonium  as  a  test  for  proteids,  8. 

of  magnesium  as  a  test  for  globulin,  8. 
Suppuration  as  cause  of  waxy  disease,  116. 
Surgical  kidney,  191. 
Sutton.     See  Gull. 
Syntonin,  2. 

Temperature,  elevation  of,  as  a  cause  of  albuminuria,  129. 

favouring  transudation  through  membranes,  1 30. 
Tension,  vascular,  abnormal,  60.     See  Arterial. 
Tests  for  albumen,  3  et  seq. 

for  peptones,  9. 
Test-papers,  Oliver's,  12. 
Test-pellets,  Pavy's,  12. 

Thomson  on  albuminuria  in  scarlet  fever,  125. 
Tracheotomy  for  cedema  glottidis,  94,  221. 
Transudation  of  albumen,  50. 
Treatment  of  malarial  albuminuria,  127. 

of  dietetic  albuminuria,  146,  148. 

of  albuminuria,  Fothergill's,  212. 

by  drugs,  212. 

of  nephritis,  214. 

of  urseniia,  217. 

of  dropsy,  218. 

of  cirrhosis,  218. 

of  waxy  disease,  219. 

in  mixed  forms,  219. 

of  complications,  220. 

of  renal  disease  with  pregnancy,  222. 

of  febrile  albuminuria,  222. 

of  albuminuria  due  to  heart  disease,  222. 

due  to  digestive  derangement,  223. 

of  functional  albuminuria,  223. 


248  INDEX. 

Treatment — continued. 

of  accidental  albuminuria,  224. 
Tube  casts.     See  Casts. 
Typhoid  fever,  albuminuria  in,  125. 
Typhus  fever,  albuminuria  in,  125. 

Ulcerated  surfaces,  absorption  of  albumen  by,  134. 
Uraemia,  69. 

with  dropsy,  71,  72. 

acute,  with  coma  and  convulsions,  99. 

treatment  of  acute,  100,  217. 

chronic,  100. 

chronic  with  delirium,  101  et  seq. 

causes  of,  105. 

in  mixed  cases,  105. 

diagnosis  from  paralysis,  106. 

with  organic  change,  112. 

in  cirrhosis,  treatment  of,  219.    . 
Urates  in  urine,  131,  148,  160,  181. 
Urea,  amount  of,  in  nephritis,  72. 

in  cirrhosis,  79,  205. 

in  early  cirrhosis,  81. 

in  advanced  cirrhosis,  110. 

in  waxy  disease,  115. 

in  circulatory  disease,  131. 

effect  of,  on  circulation,  151. 

in  albuminuria  from  exertion,  156. 

in  cyclic  albuminuria,  163. 

in  simple  persistent  albuminuria,  166. 

value  of  in  diagnosis,  180. 

in  fever,  181. 

in  albuminuria  from  eggs,  197. 

formation  of,  197. 

effect  of  diets  on  amount  of,  203  et  seq. 

excess  of,  as  a  cause  of  albuminuria,  53. 
Uric  acid,  142,  160. 

increase  of,  in  cirrhosis,  87. 
Urinary  secretion,  normal,  49. 
Urine,  characters  of,  in  acute  nephritis,  69. 

in  chronic  nephritis,  73. 

in  cirrhosis  of  kidneys,  77. 

in  cirrhosis  with  waxy  disease,  102. 

in  waxy  disease,  114  et  seq. 

in  prealbuminuric  stage  in  nephritis,  125. 

in  albuminuria  with  parametritis,  127. 


INDEX.  24!) 


Urine,  characters  of — continued. 
in  strangulated  hernia,  128. 
in  pyrexial  albuminuria,  129. 
in  circulatory  disease,  131. 
in  hepatic  derangement,  135. 
in  cyclic  albuminuria,  141. 
in  paroxysmal  albuminuria,  142. 
in  paroxysmal  hsemoglobinuria,  143. 
in  dietetic  albuminuria,  1 48. 
in  simple  persistent  albuminuria,  166. 
during  catamenia,  169. 
quantity  of,  in  diagnosis,  180. 

Valvular  disease  of  heart  in  cirrhosis,  89. 

in  nephritis,  92. 

treatment  of,  220. 
Vascular  changes  as  a  cause  of  cyclic  albuminuria,  164. 
Vascular  tension,  abnormal,  60.     See  Arterial. 
Vasomotor  nerves,  course  of,  65. 
Veins,  renal,  ligature  of,  62,  132. 
Venous  congestion,  albuminuria  from,  130,  131,  132. 
Vessels,  alterations  of,  in  waxy  disease,  122. 
Von  Noorden  on  albuminuria  among  soldiers,  18. 

on  functional  albuminuria,  141. 

Wagner  on  polyuria  in  waxy  disease,  118. 
Walking,  as  a  cause  of  albuminuria,  159. 
Walnuts,  as  a  cause  of  albuminuria,  199. 
Water,  dilution  with,  as  a  test  for  globulin,  8. 
Wateriness  of  blood,  51. 
Waxy  kidney,  complications  of,  86  et  seq. 

gastro-intestinal  derangements  in,  86. 

anaemia  in,  87. 

cardiac  and  arterial  changes  in,  92. 

phthisis  with,  95. 

eye  symptoms  in,  98. 

uraamia  in,  99,  105. 

with  cirrhosis,  104. 

paralytic  symptoms  in,  109. 

albuminuria  from,  114. 

polyuria  in,  114,  117,  180. 

case  of,  115. 

amount  of  urea  in,  115,  180. 

diagnosis  of,  116. 

causes  of,  116. 


250  INDEX. 

Waxy  kidney — continued. 

with  waxy  disease  of  other  organs,  117. 

Wagner's  groups  of,  118. 

pathological  anatomy  of,  120,  121. 

modes  of  termination  of,  120. 

recovery  from,  120. 

cause  of  albuminuria  in,  122. 

alterations  of  vessels  in,  122. 

prognosis  in,  189. 

diet  in,  200,  206. 

treatment  of,  219. 
Westphal,  experiments  of,  52. 
Whooping-cough,  albuminuria  in,  44. 
Wind  instruments,  albuminuria  in  boys  playing,  29. 
Wundt  on  saltless  diet,  54. 

Yeo  on  means  of  diminishing  albuminuria,  140. 


ERRATA. 


Page    9,  for  "  derivations  "  at  foot  of  page,  read  "  derivatives." 
„     18  and  23,  for  "Van  Noorden,"  read  "Von  Noorden." 


LORIMER    AND   GILLIES,    PRINTERS,    31    ST.    ANDREW   SQUARE,    EDINBURGH. 


